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Manifestations of Systemic Disorders Flashcards

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1
Q

Pyoderma gangrenosum
Characteristics?

Associated with chronic underlying inflammatory or malignant? 5

A
  1. Characteristics
    - Rapidly evolving, idiopathic, chronic and severely debilitating ulcerative skin disease

Associated with chronic underlying inflammatory or malignant disease:

  1. Chronic Ulcerative colitis**
  2. Chronic active hepatitis
  3. Rheumatoid arthritis
  4. Crohn’s disease
  5. Hematologic malignancies
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2
Q

Pyoderma gangrenosum

  1. Hx? 3
  2. PE? 4
  3. Most common sites?3
A
  1. History:
    - Acute onset with
    - painful hemorrhagic pustule or painful nodule
    - surrounded by erythematous halo.
  2. PE:
    - Breakdown with ulcer formation with dusky red or purple borders, -irregular and raised,
    - boggy with perforations that drain pus.
  3. Most common sites:
    - Lower extremities,
    - buttocks,
    - abdomen
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3
Q

Pyoderma gangrenosum

Treatment?

A
  1. Treat underlying disease
  2. Avoid trauma
  3. High dose systemic (IV) corticosteroids****
  4. Systemic immunosuppression
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4
Q

Pyoderma gangrenosum: what kind of systemic immunosuppressants would we use? 3

A
  1. Sulfasalazine
  2. Cyclosporine
  3. Infliximab
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5
Q

Diabetic Associations

5

A
  1. Acanthosis nigricans
  2. Necrobosis lipoidica diabeticorum
  3. Granuloma annulare
  4. Thrush
  5. Intertrigo
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6
Q

Acanthosis nigricans
Characteristics? 2

Associated with what? 3

A

Characteristics:

  1. Velvety thickening and
  2. hyperpigmentation of the skin.***** (buzz words)

Associated with:

  1. Endocrine disorders
  2. Obesity
  3. Internal malignancy (will affect the mucous membranes more so than the other causes)
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7
Q

Which endocrine disorders are associated with Acanthosis nigricans? 2

What malignancies are most common?

A
  1. Diabetes
  2. Insulin resistant syndromes** (most commonly)

GI most common (will affect the mucous membranes more so than the other causes)

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8
Q

Acanthosis nigricans
Hx? 2
PE? 4
Most common sites? 4

A

History:

  1. Insidious onset;
  2. first visible change is darkening of pigmentation

PE:

  1. Hyperpigmentation,
  2. velvety looking,
  3. skin line accentuated,
  4. surface becomes wrinkled or creased.

Most common sites:

  1. Axilla,
  2. neck (back and sides),
  3. groin,
  4. antecubital fossae
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9
Q

Acanthosis nigricans
Rx?
3

A
  1. R/O Diabetes
  2. Treat associated disorder
  3. Usually none required
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10
Q 
Necrobiosis Lipoidica  (NL), Diabeticorum
1. 50% of pts with what have this?
  1. PE? 4
  2. Necrobiosis Lipoidica (NL), Diabeticorum Rx?
  3. Most common area?
A
  1. 50% of patients with NL are insulin dependent diabetics (longstanding Type I)
  2. PE:
    - Oval, violaceous patch that expands slowly.
  • Advancing border is red and the central area turns yellow-brown.
  • Telangiectasias become prominent.
  • Ulceration is possible esp. after trauma.
    3. Difficult to treat, refer to derm
    4. On the shin
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11
Q

Granuloma Annular

  1. Characteristics? 3
  2. SLight associated with what?
  3. Common in who?
  4. Hx? 1
  5. PE? 2
  6. Most common site?3
A
  1. Characteristics (arranged in a ring)
    - Self limiting,
    - asymptomatic,
    - chronic dermatosis
  2. Slight association with diabetes
  3. More common in older women
  4. History:
    - Slowly increases over months, duration is variable
  5. PE:
    - Smooth, shiny firm ring of flesh colored papules and plaques (1 to 5cm)
    - Annular with central depression
  6. Most common site:
    - dorsum of hands and feet,
    - extremities, and
    - trunk
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12
Q

Granuloma Annular
Treatment?
3

A 
1. Treatment  (not necessary)
Disappears in 75% of pts in 2 years.
If needed:
2. Potent topical steroids
3. Intralesional injections of steroids
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13
Q

Intertrigo Characteristics? 2

Related to what infections? 3

Associated with what disease? 3

Most common sites? 4

Dx?

A
  1. Irritation in the skin folds
  2. Worse with heat and moisture

Related to

  1. Candida,
  2. Fungus Irritation and
  3. Secondary bacterial infection (Group A & B strep, pseudomonas)

Associated with

  1. Diabetes,
  2. HIV,
  3. obesity

MOst common sites?

  1. Axilla,
  2. groins,
  3. gluteal folds,
  4. overlapping abdominal panniculus

Dx?
1. KOH smear

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14
Q

Intertrigo
PE? 4

Treatment?
3

What should be avoided?

A

PE:

  1. Erythema,
    • or – pruritis,
  3. tenderness,
  4. erythematous plaques
Treatment:
1. Keep cool and dry (hairdryer)
Treatment based on cause
2. Antifungal/antibacterial powders
3. Zinc oxide ointment reduces friction
  1. Topical steroids should be avoided
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15
Q
  1. What is Thrush?
  2. What do the lesions look like?
  3. Associations? 3
  4. Treatment? 3
A
  1. Yeast infection, usually candida.
  2. White plaques or red erosive areas in the oral mucosa
  3. Associations
    - Diabetes
    - HIV
    - Immunosuppresion
  4. Treatment
    - Antifungal troches,
    - fluconazole,
    - itraconazole
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16
Q

Other systemic disorders that manifest dermatologic symptoms

4

A
  1. LUPUS
  2. DERMATOMYOSITIS
  3. SCLERODERMA
  4. XANTHOMA
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17
Q 
LUPUS
#1  Chronic cutaneous (discoid)
1. What will the lesions look like? 3
2. Progression to what is uncommon?
3. Treatment? 2
A
    • Scarring,
    • dispigmented,
    • scaly plaques on face primarily.
  2. Progression to systemic lupus is uncommon
  3. Treatment with
    - potent topical steroids
    - +/- antimalarials (hydroxycholorquine)
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18
Q 
Lupus
#2  Subacute cutaneous
1. What population more common?
2. What are the skin lesions here?
3. 50% meet criteria for what?
4. Can be induced by what?
5. Treatment with what? 2
A
  1. White women age 15-40
  2. Polycyclic scaly plaques in sun exposed areas
  3. 50% meet criteria for systemic lupus.
  4. Can be drug induced
  5. Treatment with
    - antimalarials or other
    - immunosuppressants.
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19
Q 
#3  Systemic lupus erythematosus (SLE)
1. What will the skin manifestations look like? 4
  1. Skin involvment in SLE in what %?
  2. Treatment? 2
A

3 Systemic lupus erythematosus (SLE)

    • “Butterfly” facial erythema which is nonscarring
    • Photosensitivity
    • Oral ulcers
    • Discoid lupus
  2. Skin involvement in 80% of SLE
  3. Treatment:
    - antimalarials and
    - immunosuppression
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20
Q

Dermatomyositis
Dermatitis characteristics? 5

Myositis characteristics? 2

Treatment? 2

What is present in the majority of these pts?

A
  1. Erythema,
  2. photosensitivity,
  3. heliotrope eyelid rash
  4. Gottron’s papules
  5. Calcinosis cutis (calcium deposits in the nails)
  6. Weakness of proximal muscles
  7. Elevation in muscle enzymes
  8. Steriods and methotrexate
  9. Malignancy
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21
Q

Where are Gottron’s papulse found?

3

A
  1. knuckles,
  2. periungual telangiectasia,
  3. poikiloderma (red, white, brown)
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22
Q

Scleroderma
Clinical presentation?
(CREST) 5

Treatment?

A
  1. Calcinosis (calcified lesions in hands)
  2. Reynaud’s phenomenon
  3. Esophageal dysmotility
  4. Sclerodactyly
  5. Telangiectasia

Treatment with systemic immunosuppressio

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23
Q

Progressive systemic sclerosis is what?

Treatment?

A
  1. Generalized sclerosis with internal organ involvement (heart, lungs, GI, kidney)
  2. Treatment with systemic immunosuppression
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24
Q

Xanthomas

  1. What are they?
  2. What do they look like? 2
  3. Associations? 4
  4. Common sites? 2
A
  1. Lipid deposits in skin and tendons.
    • Yellow-brown, pinkish or orange
    • macules, papules, plaques, nodules

Associations

  • Hyperlipidemia
  • Biliary cirrhosis,
  • Diabetes,
  • CRF

Common sites

  • Upper and lower eyelids,
  • inner canthus
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25
Q

What are the types of xanthomas?

3

A
  1. Eruptive xanthomas
  2. Tuberous xanthomas
  3. Tendinous xanthomas
26
Q

Whats the most common of all the xanthomas?

A

Xanthelasma

creamy orange

27
Q

Xanthelasma

  1. Most common causes unrelated to what?
  2. When seen in children or young adults, it is associated with what?
  3. Occurs in individuals over what?
A
  1. Most cases unrelated to hyperlipidemia
  2. Occurs in individuals >50 y/o
  3. familial hypercholesterolemia.
28
Q

Xanthomas
1. DX? 2

  1. RX? 4
A
  1. Check for hyperlipideima, although >50% of these patients have no metabolic disturbance.
  2. If + hyperlipidemia, CV disease may be expected.
  3. Laser,
  4. excision,
  5. electrodesiccation or
  6. topical application of trichloroacetic acid.
29
Q

DESQUAMATION DISORDERS

3

A
  1. Erythema Multiforme
  2. Stevens-Johnson Syndrome
  3. Toxic Epidermal Syndrome
30
Q

Erythema Multiforme:
Multiple morphologic presentations
5

A
  1. Erythematous “targetoid” macules / patches
  2. Papules / plaques
  3. Vesicles / bullae
  4. Wheals (urticaria)
  5. Erosions
31
Q

Erythema Multiforme

EM Minor characteristics? 2
Due to? 2

EM Major? 3
Due to? 3

A
  1. Little or no mucous membrane involvement
  2. Few (if any) systemic symptoms
  3. Often due to
    - HSV (sometimes subclinical, often recurrent)
    - Can be due to medications
  4. Always with mucous membrane involvement
    - 2 or more sites
  5. Skin involvement more widespread
  6. Systemic symptoms such as fever
    • Hepatitis,
    • nephritis
    • Often due to medications
32
Q

Erythema Multiforme
Almost any medication!!!
BUT frequent of offenders? 4

A
  1. Sulfa containing drugs
    - bactrim,
    - dapsone
  2. Anti-epileptic drugs
    - phenytoin,
    - carbemazepine,
    - phenobarbital)
  3. Antibiotics:
    - penicillin,
    - cephalosporins
  4. Allopurinol
33
Q

Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
1. Mucocutaneous drug-induced or idiopathic reaction patterns characterized by what?
2. followed by?
3. SJS is considered the maximal variant of what?
4. WHat is considered the maximal form of SJS?

A
  1. skin tenderness and erythema of skin and mucosa,
  2. followed by extensive cutaneous and muscosal epidermal necrosis and sloughing.
  3. SJS is considered a maximal variant of Erythema Multiforme Major.
  4. TEN is considered a maximal variant of SJS.
34
Q

Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
1. Onset?
2. Associated with what? 4

A
  1. Onset at any age, but most common >40 y/o
  2. Associated with:
    - Drugs are clearly the leading cause (Onset 1-3 weeks after drug exposure)
    - Systemic Lupus
    - HIV
    - HLS-B12
35
Q

Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
1. Prodrome? 5
2. Progression? 4

A
  1. Prodromes
    - Rash - Morbilliform, diffuse erythema
    - Fever
    - Mouth lesions
    - Flu like symptoms 1-3 days prior to mucocutaneous lesions
    - Mucocutaneous lesion, skin pain, burning and itching
  2. Progression
    - Necrotic epidermis, macular areas
    - Sheet-like loss of epidermis
    - Flaccid blisters that spread with lateral pressure (Nickolsky sign) on erythematous areas.
    - With trauma, full thickness epidermal detachment yielding exposed, red, oozing dermis resembling a second-degree burn.
36
Q

Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
Other organs such as what may be involved? 3

A
  1. Hepatitis,
  2. Nephrititis,
  3. Pneumonitis
37
Q

What does TEN stand for what?

Mortality?

A

Toxic Epidermal Necrolysis

5- 40% mortality rate with TEN

38
Q

Drugs associated with SJS and TEN

14

A
  1. Sulfa drugs
  2. Barbituates
  3. Allopurinal
  4. Diclofenac
  5. Sulindac
  6. Ketoprofen
  7. Ibuprofen
  8. Naproxen
  9. Cephalosporins
  10. Fluroquinolones
  11. Vancomycin
  12. Aminopenicillins
  13. Rifampin
  14. Ethambutol
39
Q

Em minor/major treatment? 3

SJS/TEN treatment? 6

A

EM Minor/Major:

  1. Antiviral prophylaxis to control HSV
  2. Steriod burst pack
  3. Early diagnosis and cessation of suspected causative drug

SJS/TEN:
1. Early diagnosis and cessation of suspected causative drug

  1. Supportive care – ICU, fluids.
  2. Systemic steroids controversial – maybe helpful in early disease.
  3. Growing evidence for the use of IVIG, halts progression if administered early.
  4. Treat eye lesions with Erythromycin ointment
  5. Transfer to burn unit if widespread sloughing
40
Q

Drug rash
1. Can happen within what time period?

  1. Very common with what?
  2. What area?
A
  1. 2 days of the onset of therapy to weeks after therapy is over.
  2. Bactrim (Septra)
  3. Chest
41
Q

Treatment of drug rash?

4

A
  1. Benadryl
  2. IV/IM steroids
  3. Steroid dose pack
  4. Try not to sweat at night, don’t use covers
42
Q

Bacterial Endocarditis

  1. What bug? 2
  2. What is it? 3
  3. Incidence is increasing in who?
  4. Hx?4
  5. PE? 3
A

Characteristics
1. Staph Aureus, Strep Viridans

  1. Proliferation of microorganisms on the endocardium of the heart.
  2. Incidence is increasing in the
    - elderly,
    - IVDU, and
    - those with prosthestic valves.
  3. History
    - Fever,
    - chills/sweats,
    - anorexia/wt loss
    - malaise
  4. PE
    - Heart murmur
    - Arterial emboli
    - Splenomegaly
43
Q

Bacterial Endocarditis skin lesions?

4

A
  1. Janeway lesions
  2. Osler’s node
  3. Subungual Splinter hemorrhage
  4. Petechial lesion
44
Q

Describe the following:

  1. Janeway lesions 3
  2. Osler’s node 3
  3. Petechial lesion? 2
A
    • Nontender,
    • hemorrhagic maculopapular
    • lesions on palms and soles.
    • Painful,
    • red nodules on
    • fingertips
    • Small, non-blanching, reddish-brown macules on extremities, upper chest, mucus membranes. Occur in crops.

-Asymptomatic red streaks in nail bed.

45
Q

Bacterial Endocarditis

  1. Dx? 6
  2. Treatment? 5
A
    • ID at risk patients and prophylaxis
    • Blood cultures
    • CBC,
    • Chem panel,
    • Coags,
    • Echo
  2. Treatment:
    - PCN-G
    - Nafcillin
    - Gentamycin
    - Vanco in MRSA
    - Zyvox in MRSA
46
Q

Rocky Mountain Spotted Fever

  1. What bug?
  2. Common in what months?
  3. Can be fatal if not treated especailly in who?
  4. Hx? 3
  5. PE? 5
A

Characteristics

  1. Rickettsia rickettsii spirochete
  2. Common May thru September
  3. Can be fetal if not treated, especially in the elderly

History

  1. History of tick bite given in 60% of cases
  2. Ask about outdoor activity
  3. Prodrome of
    - anorexia,
    - irritability,
    - malaise

PE

  1. 1-2 weeks after tick bite:
  2. Fever (>102), chills, weakness
  3. Headache,
  4. photophobia
  5. Joint pain and weakness
47
Q

Rocky Mountain Spotted Fever
1. Skin manifestation? 3

  1. Rash begins where and spreads where?
  2. Evolves to what over hours and days? 2
A
    • Initially 2 to 6mm,
    • pink blanching macules
    • begin on extremities & spread centrally.
  2. Characteristically,
    - rash begins on wrists, forearms, ankles and
    - later on palms
  3. Evolve to papules & petechiae over hours to couple of days.
48
Q

Rocky Mountain Spotted Fever

1. RX? 2

A
  1. Treatment:
    -Doxycycline (except for PG)
    -Chloramphenical (for PG)
    Start antibiotics if diagnosis is even suspected!

Doxycyline even in children now, per the CDC!!!
Less effect on teeth than Tetracycline.
Mortality rate ~60% in elderly

49
Q

Lyme disease: Can cause what type of problems? 4

What bug?

A

A disease that can cause

  • skin,
  • joint,
  • heart and
  • nervous system problems.

Spirochete
Transmitted by the bite of an infected tick or flea

50
Q

Ticks that cause Lyme disease

3

A
  1. Deer tick: Transmits Lyme disease to humans. Found in north-central and northeastern U.S.
  2. Lone star tick: Found in Texas and has been know to transmit Lyme disease.
  3. Rocky Mountain tick: Can transmit Lyme disease as well as Rocky Mountain spotted fever.
51
Q

What kind of rash for lyme?

A

Multiple
Erythema
Migrans
(Skin rash)

52
Q

Lyme Disease: Signs and Symptoms
Stage I:
1. When is this stage?
2. What kind of symptoms develop in 7-14 days?
3. Symptoms include? 7
4. Skin lesions may appear as what?
5. Secondary skin rashes appear in nearly ____% of individuals with Lyme disease.

A
  1. 3 to 30 days after bite.
  2. Flu-like symptoms develop within 7 – 14 days.
  3. Symptoms include
    - fatigue,
    - headache,
    - fever and chills,
    - muscle and joint pain,
    - nausea, vomiting,
    - dizziness and, a
    - non-productive cough.
  4. Skin lesion(s) may appear as a small red circular rash around the bite and expand.
  5. 80%
53
Q 
Lyme Disease: Signs and Symptoms
Stage II: 
1. When does it happen?
2. Symptoms?
3. What develops in 60% of pts?
4. Fifteen percent of people infected with Lyme disease develop what?
A

Two stages of Lyme disease:
1. Stage II (Late) – May occur weeks or months after the onset of Lyme disease.

  1. Severe headache and neck pain or stiffness.
  2. Arthritis will develop in 60% of patients weeks or months after infection (rarely more than 2 years).
  3. neurological symptoms, including psychiatric problems.
54
Q

Preventing Lyme Disease6

A
  1. Take protective measures when outdoors.
  2. Wear light-colored clothing so that ticks can be easily seen.
  3. Tuck pants into boots or socks.
  4. Use a repellant containing DEET.
  5. Walk in the center of trails, and avoid contact with high grass and brush at trail edges.
    6 Keep pets free of ticks.
55
Q 
Meningococcemia
Characteristics
1. What bug?
2. Highest incidence when?
3. Season?
4. Most rapidly lethal form of what?
A
  1. Neisseria meningitidis
  2. Highest incidence between 6 mos. and 3 years of age.
  3. Highest incidence, midwinter, early spring
  4. Most rapidly lethal form of septic shock
56
Q

Meningococcemia
1. PE? 5

  1. Early Exanthem
    - Color and Size?
    - What will they look like?
    - Where at? 4
  2. Later lesions will look like what? 3
A
  1. PE
    - High fever,
    - tachycardia,
    - mild hypotension,
    - signs of meningeal irritation
    - patient appears acutely ill.
2. Early Exanthem
Occurs soon after onset
-Pink 2mm-10mm 
-macules/papules, 
-sparsely distributed on trunk/lower extremities, face, palate, conjunctivae.

Later lesions

  1. Petechiae in center of macules
  2. Lesion become hemorrhagic within hours, purpura
  3. Purpura fulminans, hemorrhagic bullae
57
Q

Menigococcemia
Dx? 3

RX? 4

A
  1. Blood cultures
  2. Pus from nodular lesion shows gram neg. diplococci
  3. D-dimers

Treatment

  1. Cefotaxine (Claforin)
  2. Ceftriaxone (Rocephin)
  3. PCN-G
  4. Hemodynamic stabilization
58
Q

Gonococcemia

  1. What bug?
  2. What does the early bacteremic phase consist of? 3
  3. Peak incidence in what age?
    - males
    - females
  4. The classic skin lesions are what?
A
  1. Neisseria gonorrhoeae
  2. early bacteremic phase consisting of
    - tenosynovitis,
    - arthralgias, and
    - dermatitis
  3. peak incidence in
    - males aged 20-24 years and
    - females aged 15-19 years
  4. The classic skin lesions are acral hemorrhagic pustules.
59
Q

Gonococcemia
The joints most commonly involved include those of the extremities, including the what?

About 75% of patients experience a dermatitis that can vary from what? 3

A
  1. wrists,
  2. the fingers,
  3. the elbows,
  4. the knees, and
  5. the ankles,
    with 70% of patients experiencing a migratory polyarthralgia of 1-3 joints and the remaining 30% having involvement of more than 3 joints.
  6. macular/papular to
  7. vesicular/pustular to
  8. necrotic or hemorrhagic erythema.
60
Q

Labs of Gonococcemia? 3

A
  1. CBC
  2. ESR
  3. Culture
61
Q

Gonococcemia treatment?

6

A
  1. Hospitalization with IV antibiotics
  2. Empiric tx with Rocephin
  3. PCN-G
  4. Augmentin
  5. Doxycycline and
  6. Azithromycin

Dermatology (12 decks)

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