Dermatology Emergencies- Belazarian Flashcards
Describe DRESS and the common drugs associated with this syndrome.
Drug Rash, Eosinophilia, and Systemic Symptoms
- Potentially fatal hypersensitivity to a med
- Caused by alteration in drug metabolism- possibly due to HHV6.
Anticonvulsant Drugs:
- Phenytoin
- Carbamazepine
- Phenobarbital
Describe the Clinical Picture of DRESS
- Onset 4-6 weeks after starting drug
- Fever initially
- EDEMA of the face (hallmark)
- Eosinophilia
- Liver
- Joints
- Any major organ system
Describe the treatment of DRESS
- Discontinue Offending drug
- Corticosteroids
Note: Death usually due to fulminant hepatitis.
Describe Erythema Multiforme
- AKA Erythema Multiform Minor
- Self Limited and Recurrent (1-4 week Episodes)
- Young adults
- Targetoid Lesions (3 zones, Can be a bulla)
- Acral
Note: This is part of the Continuum
Describe the etiology of Erythema Multiform
- Herpes Simplex (1-3 weeks before)
- may or may not be clinically evident - Mycoplasma
Describe the treatment of Erythema Multiforme
Prevention of Herpes Outbreak
- Sunscreen
- Antivirals (Acyclovir, Valacyclovir)
Describe Steven Johnson Syndrome
- AKA Erythema Multiform major
- < 10% of total BSA involved
- 2 or more mucous membranes involved
- Atypical targets (not 3 zones)
Describe the Clinical Features of Steven Johnson Syndrome
GFR PPD
- Gritty eyes
- Fever/ Flu-like prodrome
- Red Tender skin –> Sloughing
- Photosensitivity
- Painful urination and bowel movements
- Difficulty swallowing or eating
Describe Toxic Epidermal Necrolysis
- > 30% of total BSA involved
- Target lesions are not common.
Describe the Clinical features of Toxic Epidermal Necrolysis
GFR PPD BNS
Gritty Eyes Fever / Flu prodrome Red tender skin Photophobia Painful urination/ bowel movements Difficulty swallowing/ eating
Blisters*
Nikolsky Sign*
Skin Sloughing*
Histo: Epidermal Necrosis
List the causes of SJS and TEN
- Trimethroprim-Sulfamethoxazole
- Antibiotics
- Anticonvulsants
- Allopurinol
- NSAIDS
Discuss the management of SJS and TEN
- Withdraw offending drug
- Burn Unit
- Fluids/electrolytes
- Temperature
-IV Steroids and/or Immunoglobulins (Controversial)
What is the mortality rate for SJS and TEN
- 5%
- 30%
Describe Exfoliative Erythroderma
- Many Etiologies
- Redness and Scaling over >90% of the body
- Older patients
Describe the clinical features of Exfoliative Erythroderma
- Pruritis and Fatigue
- Redness and scaling
- Dermatopathic lymphadenopathy
Describe some of the associated etiologies of Exfoliative Erythroderma
AC IPAD
Atopic Dermatitis Cutaneous T cell Lymphompa (mycosis fungoides) Idiopathic Psoriasis Allergic Contact Dermatitis Drug Reaction
Name the emergency sequelae of Exfoliative Erythroderma
HD PIC
- Heat fluid loss through skin –> Temperature instability
- Dehydration
- Protein loss
- Infections
- Congestive Heart failure (High output)
Describe the management of Exfoliative Erythroderma
- Stop the offending drug
- Treat underlying skin condition
- Supportive Therapy: Temp, Fluids, hemodynamics
- Topical Steroids
What is the mortality range for Exfoliative Erythroderma?-
- 4.6 to 64%
- Relapse is common
Name the causative agent for Meningococcemia and describe the common setting that outbreaks are observed
- Neisseria Meningitides
- Schools
- Military Barracks
Note: Transmission is through inhalation of aerosol droplets.
- Nasopharyngeal infection
- Hematogenous dissemination
Describe the pathophysiology of meningococcemia
Polysaccharide capsule important for virulence and serotyping
- Damage to endothelium and release of LPS
- Results in release of TNFa, IL-1, IL-6, and INFgamma
These Cytokines cause:
- Hypotension
- DIC
- Multi-organ failure
- Increased Vascular Permeability
Describe the risk factors for development of meningococemia
- Young age
- Asplenia
- Immunoglobulin deficiency
- Late complement deficiency (C5-C9)
Describe the clinical features of Meningococemia
- Petechiae
- Angular or Stellate lesions (with GUNMETAL grey center)
- Pupura Fulminans
- Fever Chills and Hypotension
- Meningeal signs (80% develop meningitis)
Describe the Diagnosis and Treatment of Meningococcemia
Dx:
- CSF and Blood Culture
- Gram stain of Pustules show Gm-negative Diplococci
Rx:
- Ceftriaxone
- Ampicillin
- What is the causative agent for Rocky Mountain Spotted Fever
- What is the tick species that serves as the vector?
- What state is it common?
- Rickettsia Rickettsii
- Dermacentor tick
- Common in North Carolina
- Rarely in the Rocky Mountain states
Describe the Pathogenesis of Rickettsia Rickettsi
- Replicates in endothelium of Dermis
- Spreads hematogenously and attaches to endothelial cell
- Results in Vascular/ tissue injury
Describe some of the systemic sequelae of Rocky Mountain Spotted fever
Multi-organ failure due to:
Vasculitis in:
- Brain
- Heart
- Lungs
- GI
- Kidneys
- Liver
Also promotes Coagulation cascade, resulting in:
- Hypercoagulability
- Thrombocytopenia
Describe the Clinical Features of Rocky Mountain Spotted Fever
- Fever
- Headache
- Photophobia
- Hypotension
- Blanchable macules –> Non-blanchable Papules (Hemorrhagic)
- Starts on Wrists / Ankles –> Palms/ Soles –> Trunk / Face
What is the Classic Rocky Mountain Spotted Fever Triad?
- Fever
- Rash
- Headache
What is the Gold Standard Rx for Rocky Mountain Spotted Fever?
Doxycycline
Note: We use the Dox to kill Dermacentor
What is the pathogen implicated in Toxic Shock Syndrome?
What is the alternate (and more common) pathogen implicated in another variation of this syndrome?
- Staph Aureus
- Strep Pyogenes causes Streptococcal Toxic Shock Syndrome
- More common!
Describe the pathogenesis of s. aureus in TSS
There is a massive release of cytokines due to bacterial toxins acting as Superantigens.
Describe the clinical picture of TSS
- Generalized macular erythema (especially at the flexures)
- Mucus membranes can be involved- strawberry tongue
-Follwed by 1-2 weeks of desquamation especially at palms and soles of feet.
Describe the treatment for TSS
- IV fluids and vasopressors
- Penicillinase resistant antibiotics
Describe the mortality rates for the toxic shock syndrome caused by s. aureus and s. pyogenes, respectively.
Staph TSS mortality rate > 5%
Strep TSS mortality rate 30-70%
What predisposes young girls to Staph aureus TSS?
Tampon Use
In what population subtypes do we see disseminated HSV
- Immunocompromised (HIV)
- Newborns
- Pregnant
- Malignancies
Patients with what skin condition are at risk for developing a viral associated condition?
Patients with ECZEMA are at risk for developing:
ECZEMA HERPETICUM
What is the clinical appearance of disseminated HSV?
Clustered Erosions
What do we use to diagnose Disseminated HSV?
To detect HSV, we use TDV
- Tzanck smear
- Direct Fluorescent antibody (DFA)
- Viral Culture
What is the Rx for Disseminated HSV?
IV Acyclovir
Describe the Artheroembolic disease in its entirety
- Small deposits of fibrin and cholesterol debris embolize from location and into smaller vessels in skin.
- Spontaneous onset after intra-vascular procedure
- Violaceous vascular pattern or blue toe; signs of necrosis
- Can affect many organs
- Dx: Biopsy
- Rx: Anticoags.
What is Calciphylaxis and what patients are at high risk for this?
- Rare and serious condition in which there is calcification of the cutaneous arteries leading to tissue necrosis.
- Patients with ESRD on dialysis are at increased risk for this.
Describe the clinical picture for Calciphylaxis
Sudden onset of intense PAIN from necrotic/ indurated lesions.
Common locations:
Thighs
Butt
Lower abdomen
Describe the Diagnosis, Management, and Mortality of Calciphylaxis.
Dx:
- Deep biopsy showing Calcification of subcutaneous fat
- Calcification of Medial layer of arterioles
Rx:
- Control Calcium and Phosphorus levels
- Parathyroidectomy (controversial)
Mortality:
-80%
What is Porphyria Cutanea Tarda (PCT)?
- Most common type of Porphyria
- Fragile skin- bullae and vesicles on the hands after minor trauma.
- Sporadic and acquired- d/t deficient enzyme in the Heme pathway
- Alcohol exacerbates
Describe Pyoderma Gangrenosum
- Characterized by neutrophilic infiltration of the dermis and destruction of tissue
- Rapidly progressive
- Pustule –> Painful Ulcer with bluish edge
- Can be as deep as the bone!
-Associated with IBDs and RA
What is Erythema Nodosum?
A delayed type hypersensitivity response to a variety of different antigenic stimuli
Where in the body are we likely to see the clinical manifestations of Erythema Nodosum?
- Lower Legs, bilaterally.
- Anterior is common
What are some of the common trigger of Erythema Nodosum?
Sarcoidosis TB UC Crohn's Kontraceptive Oral pills
Structurally, what part of the skin is afflicted in Erythema Nodosum?
Inflammation Deep into the fat layer
-results in the firm nodules
Describe the category of pathology of Erythema Nodosum
-Panniculitis (inflammation of the subcutaneous fat)
What kind of biopsy is needed for Erythema Nodosum?
- Deep punch biopsy (Punch in a Punch biopsy)
- Must get some SubQ fat
Note: We will see Granulomatous inflammation with Multinucleated Giant Cells
What is the Rx for Erythema Nodosum?
Treat underlying disorder.
- NSAIDS
- Bed rest
What is Herpes Zoster?
- AKA Shingles
- Recurrent infection with Vericella Zoster
- Reactivation of latent virus in the sensory ganglia
- Trunk Location
- Dermatomal
What type of person gets Herpes Zoster?
- Elderly
- Immunocompromised
Is Herpes Zoster contagious?
- Can be but VERY rare.
- Usually only Immunocompromised person
Herpes Zoster is a reactivation of VZV thus it is unlikely to develop zoster as a result of contact.
What is the most common complication of Zoster?
Postherpetic Neuralgia
- Pain that lasts after lesions hav healed
- Lasts > 4 wks after onset of lesions.
Very painful
What is the Rx for Herpes Zoster?
Symptomatic Treatment
- Antihistamines
- Analgesics
- Cool Compress
If older than 50
-Systemic Antivirals (esp if lesions started within 72hrs ago)
Hemorrhagic Crusting is classic for what condition?
Steven Johnson’s
How is Steven Johnson’s different from TEN?
Body surface area afflicted.
-Less than 10% vs Greater than 30%
What are some of the optical complications that can result from Steven Johnson’s Syndrome?
Due to mucosal and eye involvement:
- Inflammation/fibrosis/scarring of the eyes
- Even vision loss
