Viral Exanthems & Soft Tissue Tumors Flashcards
Measles (Rubeola)
Etiology: Paramyxovirus
Highly contagious, 9/10 susceptible close contacts will develop measles
Transmitted: Infectious droplets
- cough, sneeze, close breathing
Consider recent travel in HPI when patient presents with febrile rash
Clinical Stages of Measles (Rubeola)
Incubation Period: approx 2-3 weeks (median 13 days)
- typically asymptomatic
Prodrome: anorexia, malaise, fever (105+)
- Followed by 3 C’s: cough, coryza, conjunctivitis
Enanthem: Koplik spots (48 hours prior to rash)
Exanthem (rash): blanching, maculopapular
- Starts on face and spreads from head to toe (typically spares palms and soles)
- Infectious 5 days before rash and 4 days after
Koplik Spots
Cluster of tiny bluish-white papules on buccal mucosa
“Grains of salt on a red background”
Diagnosis of Measles (Rubeola)
Clinical Presentation is key
Serum or throat swabs for histologic analysis (urine may also contain virus)
- Measles RNA RT-PCR
- Serology: Measles virus specific IgM
Complications of Measles (Rubeola)
30%
More Common: diarrhea»_space; otitis media
More Severe: 1 or 2 out of 1000 with measles will die
- pneumonia (6%): most common cause of death in
children
- Encephalitis (1:1000): rapidly progressive and fatal in
15%
- Subacute Sclerosing Panencephalitis (SSPE): 2-10
years later (1:10000 but higher in babies 1:600)
- Fatal degenerative disease of central nervous system
(fatal within 1-3 years)
- behavioral and intellectual deterioration, seizures
Highest Risk Groups: pregnant woman, immunocompromised , ages <5 and >20 years old
Treatment of Measles (Rubeola)
Symptomatic treatment only
Vitamin A
Ribavirin?
Patient Education: household and close contacts, avoid contact with pregnant women, prevention by immunization (MMR)
Erythema Infectiosum (Fifth Disease)
Etiology: Parvovirus B-19
Most commonly occurs in school-aged children
- adults uncommonly affected
Transmitted by respiratory secretions
Symptoms can last for weeks, months, or rarely years
- Frequent clearing with recurrence of rash following
nonspecific stimuli (stress, sunlight, exercise, hot bath)
Clinical Stages for Erythema Infectiosum (Fifth Disease)
Incubation period: 7-14 days
Prodrome: nonspecific flu-like sxx 2-3 days
• Mild low-grade fever, coryza, HA, nausea, diarrhea, pruritus, malaise, sore throat
Facial Rash: erythematous malar rash
• “Slapped Cheek”
Body Rash: follows facial rash 2-3 d later
• LACY, pink macular rash of trunk and extremities (extensor surfaces)
*Polyarthropathy(10%): pain/inflammation of multiple joints
Diagnosis of Erythema Infectiosum (Fifth Disease)
Clinical Presentation
Additional diagnostics only if needed:
•Parvovirus B19 IgM/IgG antibodies
•Quantitative PCR for Parvovirus B19 DNA
Complications of Erythema Infectiosum (Fifth Disease)
Rare:
- Transient aplastic crisis
- In pregnancy (Hydrops Fetalis and/or fetal loss)
Management of Erythema Infectiosum (Fifth Disease)
Reassurance & symptomatic treatment
For severe anemia, may need blood transfusion and immune globin
Avoid contact with pregnant woman
Prevention: no vaccine available; but 50% of people may have immunity due to exposure in childhood
Rubella (German Measles)
Etiology: Rubella virus
Transmitted via inhaled large particle aerosols
Rubella officially declared eliminated from the Americas
Clinical Presentation of Rubella (German Measles)
Incubation: 12-23 days
+/-Prodrome: 1-5 days prior
• May be concurrent with rash
• Minimal systemic symptoms: Low grade fever (<101), lymphadenopathy, cold sxsin older kids or adults
Rash: erythematous papules/purpura • “3 Day Measles” •Pinpoint, pink maculopapules •Head to toe progression •Contagious 7 days before/after rash with highest during rash
Arthralgias/ Arthritis may accompany rash (common in adults)
Diagnosis of Rubella (German Measles)
Clinical Presentation
Nasopharyngeal Swab:
- Preferred for viral detection
- Rubella RNA detection by RT-PCR
Serology:
- Rubella IgM and IgG antibody
Complications of Rubella (German Measles)
Encephalitis (1:6000), thrombocytopenia purpura, GI hemorrhage
Birth defects in pregnant woman: Congenital rubella syndrome (lethal)
- “Blueberry Muffin”
- Hearing loss: most common
- Mental retardation
- Cardiovascular and ocular defects
Mortality
Management of Rubella (German Measles)
Symptomatic treatment only
Avoid contact with pregnant women
- Rubella titer drawn at first prenatal visit
- Up to 85% chance of fetal damage if Rubella
contracted in early pregnancy
Prevention by immunization (MMR)
- Contraindicated in pregnancy!
Roseola Infantum
Etiology: Most commonly caused by Herpes virus 6 (HHV-6)
- Mostly infants and young children (peaks 7-13 months)
- Transmission sporadically without known exposure
High Fever (102-105) -> Resolves abruptly -> Rash appears
Clinical Presentation of Roseola Infantum
Incubation: 9-10 days
Prodrome: Febrile phase
•3-5 days of high fever (potentially > 105 degrees) with abrupt end
•Irritability and potential for seizures
•Other: lymphadenopathy, erythematous tympanic membranes malaise, anorexia, bulging fontanelle
Rash: blanching pink/erythematous maculopapular
•Spreads from neck /trunk initially then to face/extremities
•Typically nonpuritic
•Nontoxic appearance
- Except immunocompromised
Diagnosis of Roseola Infantum
Clinical Presentation
Serology: only if immunocompromised
Treatment: supportive treatment (antipyretics)
Hand, Foot, & Mouth
Etiology: Coxsackie A16 virus
Mostly affects children <5yo
Transmission: oral ingestion of the virus
- fecal-oral or oral/respiratory secretions (vesicles)
Clinical Presentation of Hand, Foot, Mouth
Incubation period: 3-5 days
Prodrome: 12-24 hours
•Typically absent
•Fever, fussiness, emesis, abdominal pain, diarrhea
Oral enanthem/exanthem:
•Sore throat, vesicles on buccal mucosa, tongue
•Vesicles on hands, feet, and buttocks
- Vesicles may create ulcers
Diagnosis of Hand, Foot, Mouth
Clinical Presentation
Complications of Hand, Foot, Mouth
Decreased oral intake, dehydration
Encephalitis
Aseptic meningitis
Loss of nails
Fetal loss, Myocarditis, and conjunctival ulceration is rare
Treatment of Hand, Foot, Mouth
- Symptomatic treatment only
- lidocaine gel for oral discomfort?
- Prevention with good hygiene
- No vaccine currently
Molluscum Contagiosum
Etiology: Poxvirus
- Common in children
- Also seen in adults and immunocompromised
- Transmission: direct physical contact and contact with contaminated fomites (linens, clothing, towels, toys, etc.)
- Autoinoculation: Self spreading by touching, scratching, or also by shaving
Clinical Presentation of Molluscum Contagiosum
- Lesions
- Flesh colored, pearly, papules with umbilication(dimple at the center)
- 2-5 mm
- Located anywhere except palms and soles
•No associated symptoms
Diagnosis of Molluscum Contagiosum
Clinical Presentation
Histology of lesion:
- Eosinophilic cytoplasmic inclusion bodies (“molluscum
bodies”)
Treatment of Molluscum Contagiosum
- Self-limiting, but very contagious
- Usually spontaneously resolve in 6-12months
- Treatment recommended in genital region
- No Treatment
- Home treatment: Podophyllotoxin cream
- Contraindicated in pregnant women (fetal toxicity)
•Clinical Office Care: Cryotherapy, Curettage,Cantharidin
Human Papilloma Virus (HPV)
Mucosal: Condyloma Acuminata
Cutaneous: common, plantar, and flat warts
•Benign clinical lesions on skin and mucous
membranes but plays a role in oncogenesis of skin
and mucosal malignancies (ex. SCC)
•Induce epidermal proliferation -> viral induced tumors
Condyloma Acuminatum
Etiology: human papilloma virus (HPV)
•Genital Warts
•Most common anorectal infection affecting homosexual males
•Seen also in heterosexual or bisexual men and
women
•Transmission: most common is sexual contact
Clinical Presentation of Condyloma Acuminatum
Classic cauliflower-like lesions: perianal growth, mild pruritus
Diagnosis of Condyloma Acuminatum
Clinical Presentation
•Anoscopy and proctosigmoidoscopy evaluate
lesions internally (75%)
DDX: Anal squamous cell carcinoma, condylomata lata(secondary to syphilis)
Treatment of Condyloma Acuminatum
Topical (Podophyllin), Immunotherapeutic, or Surgical (electrocautery, laser, cryotherapy, excision)
Verucca Vulgaris (Common Warts)
Etiology: human papillomavirus (HPV)
- More common in children or young adults
- Transmission: skin to skin contact
- Spontaneous resolution in 1-2 years
- Recurrence is common
Clinical Presentation of Verucca Vulgaris (Common Warts)
- Lesions: Raised, rough-surfaced lesions with tiny, pigmented thrombosed capillaries (“seeds”)
- Common on hands and feet (plantar)
Diagnosis of Verucca Vulgaris (Common Warts)
Clinical presentation
•15 Blade scrape off hyperkeratotic portion, thrombosed capillary can be visualized
Treatment of Verucca Vulgaris (Common Warts)
- Nothing: spontaneous resolution may occur
- Salicylic acid (home or clinical treatment)
- Cryotherapy
- Electrodessication
- Snip or shave biopsy: filiform warts
Use #15 blade to shave down the callous prior to treatment
Varicella (Chicken Pox)
Etiology: Varicella-Zoster virus (VZV), a herpes virus
- Transmission: aerosolized droplets or direct contact with skin lesions
- Highly contagious
- Recurrence occurs
Clinical Stages of Varicella (Chicken Pox)
Incubation period: 10-21 days
Prodrome: 2-5 days
•Fever, malaise, pharyngitis, anorexia
Rash: generalized vesicular rash
•Pruritic
•Lesions occur at different stages over 4 days and are typically crusted over in 6 days
Diagnosis of Varicella (Chicken Pox)
- Visualizing lesions in all three stages at the same time
* Tzanck smear shows multinucleated giant cells
Complications of Varicella (Chicken Pox)
- Group A strep with associated complications
- Encephalitis and Reye syndrome uncommon
- Largest complications seen in immunocompromised patients
Treatment of Varicella (Chicken Pox)
- Symptomatic treatment
- Contagious until all lesions are crusted
- Avoid pregnant females!(Congenital varicella syndrome)
- Acyclovir used in immunosuppressed pts
- Vaccination (Varivax)
Herpes Zoster
Etiology: Varicella zoster virus (VZV), a herpes virus
- “Shingles”
- Causative organism is same for both varicella zoster
- Reactivation of latent VZV from dorsal root ganglia
- More common in elderly and immunocompromised patients
Clinical Presentation of Herpes Zoster
Prodrome:
•Acute neuritic pain precedes eruption by 3-5 days
•Throbbing, stabbing, burning sensation
•Pruritus, fever, headache, allodynia
Rash: Active
•Development of grouped vesicles on an erythematous base
•Eruption follows dermatomal distribution
•Unilateral
•Thoracic distribution most common
Complications of Herpes Zoster
Chronic
•Post herpetic neuralgia (PHN): lancinating pain which can last months-years after resolution of lesions (10-15%)
•Herpes Zoster Ophthalmicus(HZO)
•Sight-threatening linked to trigeminal ganglion
activation
•Hutchinson’s Sign: vesicles on the nose•Acute retinal
necrosis
•Cranial and peripheral nerve palsies
Secondary concerns:
•Comorbid depression is common
•Skin infections
•Visceral involvement
Treatment of Herpes Zoster
•START TREATMENT EARLY!!
•Within 72hours
•Accelerates healing, decreased the duration of pain
and may reduce the incidence of PHN
•Antiviral
Famciclovir(Famvir) 500mg TID x 7d
Valacyclovir(Valtrex) 1g TID x 7d
Acyclovir (Zovirax) 800mg QID+ x 7-10d
•Hydration
•Keep skin clean & dry, cover lesions
•Manage the pain!!
•Acute: Narcotics, NSAIDS
•Topical anesthetics
•Chronic: Tricyclic antidepressants, gabapentin
(Neurontin), pregabalin(Lyrica)
•Emergent ophthalmology consult if ocular involvement
•Usually resolves within 2-6 weeks
- Infectious precautions
- Can transmit varicella to seronegative patients via contact with skin lesions
- Use caution until primary crusts have healed
- Avoid pregnant women, infants, and immunocompromised individuals
Prevention of Herpes Zoster
Zostavax(2006) or Shingrix(2017)
•Both approved >50yo, Recommended for >60 by ACIP
Herpes Simplex Virus (HSV)
Etiology: Two types
HSV-I
•Most commonly oral: herpes labialis
•“Cold Sores”
•Transmitted by direct contact during viral shedding
HSV-II
•Most commonly genital: herpes genitalis
•Transmitted sexually
HSV - I
Worldwide, 90% adults have serologic evidence of HSV-I
- Commonly acquired asymptomatically in childhood
- Only 20-25% of those infected have a history of herpes labialis
Primary presentation can be severe (Oropharynx)
- Gingivostomatitis
- Pharyngitis
- Severe mouth pain and fever
HSV - II
15-20% of the US population has serologic evidence of HSV-II
- ~70% of cases transmitted during viral shedding
•Patient may be asymptomatic
- Uninfected female partners are at greater risk for infection
- 40% of newly acquired cases of genital herpes due to HSV-I
Pathogenesis of Herpes Simplex Virus (HSV)
- Spread through direct contact with active lesions, saliva, semen, cervical secretions, particularly during the viral sloughing/shedding period.
- Patient may be asymptomatic
- Virus will remain latent in nerve root ganglion following the primary infection.
- Reactivated by a change in immune status - stress, infection, menses, fatigue, sun exposure, etc.
Clinical Presentation of Herpes Simplex Virus (HSV)
Prodrome: burning, tingling or pruritus
Lesions appear: grouped vesicles on an erythematous base
–Crusting at later stages
–Associated lymphadenopathy
- 25% of recurrences abort or fail to progress beyond the prodrome phase
- Although the lesions are primarily genital and oral, they can affect any part of the body
Diagnosis of Herpes Simplex Virus (HSV)
Clinical Presentation
•Viral culture
•Fluid from vesicle
•Direct microscopy via Tzanck smear
•Fluid scraped from vesicle and stained with Wright’s
stain
•Positive if giant multinucleated cells (indicates
Herpes but not specific to type)
•Positive in 75% of early cases
- Serology
- Antibodies to HSV-I and HSV-II via Western blot
Complications of Herpes Simplex Virus (HSV)
- Erythema multiforme
- Eczema herpaticum
- Recurrent aseptic meningitis
Treatment of Herpes Simplex Virus (HSV)
•START TREATMENT EARLY!!! (<72 hours preferred)
•Initial outbreak and subsequent outbreaks:
- Valacyclovir(Valtrex)
- Famciclovir(Famvir)
- Acyclovir (Zovirax)
•Doses differ depending on whether its an initial outbreak vs. recurrence of the infection
Treatment for Chronic Suppression:
•Antivirals are also used for chronic suppression
•Herpes Labialis: >4 episodes/year
•HSV recurrences with serious complications
•Decreases frequency of recurrences and asymptomatic
shedding
•Reassess tx at 4-6 months & consider discontinuing by 1
yr
Epidermal Inclusion Cyst
- Most common cutaneous cyst
- Also called: epidermoid cyst
Clinical Presentation: •Soft, mobile nodule •Fluctuant •Often central punctum •Infected: erythema, inflammation, very painful
Treatment of Epidermal Inclusion Cyst
- Nothing: May respond spontaneously but recur often
- Uninfected: Kenalog injection, I&D, excision
- Infected: I&D, Oral antibiotics may be needed
Lipoma
- Lipoma: most common subcutaneous soft-tissue tumor (1:1000)
- Composed of adipose tissue
- Etiology is unknown
Clinical Presentation:
•Soft, mobile
•Typically non-tender
•Majority or solitary
Treatment of Lipoma
•Surgical removal: cosmesis, compression of adjacent structures, diagnosis is questionable
•Malignant concerns with larger deeper tumors and
rapid growth
Sarcoma
Rare Malignant tumor
80% soft tissue (remaining originate in bone)
Clinical Presentation:
•Enlarging, painless mass (extremities or trunk most common)
•Due to compression, pain, edema, or paresthesias
may present clinically
Management:
•Advanced imaging of primary lesion: MRI vs CT (abdominal cavity)
•Core-needle biopsy, surgical resection
•Chest CT: rule-out metastasis (+/-MRI brain)
•Multidisciplinary sarcoma team referral
