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Clin Med I > Viral Exanthems & Soft Tissue Tumors > Flashcards

Viral Exanthems & Soft Tissue Tumors Flashcards

1
Q

Measles (Rubeola)

A

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

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2
Q

Clinical Stages of Measles (Rubeola)

A

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
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3
Q

Koplik Spots

A

Cluster of tiny bluish-white papules on buccal mucosa

“Grains of salt on a red background”

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4
Q

Diagnosis of Measles (Rubeola)

A

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
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5
Q

Complications of Measles (Rubeola)

A

30%

More Common: diarrhea&raquo_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

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6
Q

Treatment of Measles (Rubeola)

A

Symptomatic treatment only

Vitamin A

Ribavirin?

Patient Education: household and close contacts, avoid contact with pregnant women, prevention by immunization (MMR)

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7
Q

Erythema Infectiosum (Fifth Disease)

A

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)

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8
Q

Clinical Stages for Erythema Infectiosum (Fifth Disease)

A

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

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9
Q

Diagnosis of Erythema Infectiosum (Fifth Disease)

A

Clinical Presentation

Additional diagnostics only if needed:
•Parvovirus B19 IgM/IgG antibodies
•Quantitative PCR for Parvovirus B19 DNA

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10
Q

Complications of Erythema Infectiosum (Fifth Disease)

A

Rare:

  • Transient aplastic crisis
  • In pregnancy (Hydrops Fetalis and/or fetal loss)
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11
Q

Management of Erythema Infectiosum (Fifth Disease)

A

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

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12
Q

Rubella (German Measles)

A

Etiology: Rubella virus

Transmitted via inhaled large particle aerosols

Rubella officially declared eliminated from the Americas

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13
Q

Clinical Presentation of Rubella (German Measles)

A

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)

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14
Q

Diagnosis of Rubella (German Measles)

A

Clinical Presentation

Nasopharyngeal Swab:

  • Preferred for viral detection
  • Rubella RNA detection by RT-PCR

Serology:
- Rubella IgM and IgG antibody

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15
Q

Complications of Rubella (German Measles)

A

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

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16
Q

Management of Rubella (German Measles)

A

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!

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17
Q

Roseola Infantum

A

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

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18
Q

Clinical Presentation of Roseola Infantum

A

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

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19
Q

Diagnosis of Roseola Infantum

A

Clinical Presentation

Serology: only if immunocompromised

Treatment: supportive treatment (antipyretics)

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20
Q

Hand, Foot, & Mouth

A

Etiology: Coxsackie A16 virus

Mostly affects children <5yo

Transmission: oral ingestion of the virus
- fecal-oral or oral/respiratory secretions (vesicles)

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21
Q

Clinical Presentation of Hand, Foot, Mouth

A

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

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22
Q

Diagnosis of Hand, Foot, Mouth

A

Clinical Presentation

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23
Q

Complications of Hand, Foot, Mouth

A

Decreased oral intake, dehydration

Encephalitis

Aseptic meningitis

Loss of nails

Fetal loss, Myocarditis, and conjunctival ulceration is rare

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24
Q

Treatment of Hand, Foot, Mouth

A
  • Symptomatic treatment only
    • lidocaine gel for oral discomfort?
  • Prevention with good hygiene
    • No vaccine currently
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25
Q

Molluscum Contagiosum

A

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
26
Q

Clinical Presentation of Molluscum Contagiosum

A
  • Lesions
    • Flesh colored, pearly, papules with umbilication(dimple at the center)
    • 2-5 mm
    • Located anywhere except palms and soles

•No associated symptoms

27
Q

Diagnosis of Molluscum Contagiosum

A

Clinical Presentation

Histology of lesion:
- Eosinophilic cytoplasmic inclusion bodies (“molluscum
bodies”)

28
Q

Treatment of Molluscum Contagiosum

A
  • 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

29
Q

Human Papilloma Virus (HPV)

A

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
30
Q

Condyloma Acuminatum

A

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

31
Q

Clinical Presentation of Condyloma Acuminatum

A

Classic cauliflower-like lesions: perianal growth, mild pruritus

32
Q

Diagnosis of Condyloma Acuminatum

A 
Clinical Presentation
     •Anoscopy and proctosigmoidoscopy evaluate 
       lesions internally (75%)

DDX: Anal squamous cell carcinoma, condylomata lata(secondary to syphilis)

33
Q

Treatment of Condyloma Acuminatum

A

Topical (Podophyllin), Immunotherapeutic, or Surgical (electrocautery, laser, cryotherapy, excision)

34
Q

Verucca Vulgaris (Common Warts)

A

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
35
Q

Clinical Presentation of Verucca Vulgaris (Common Warts)

A
  • Lesions: Raised, rough-surfaced lesions with tiny, pigmented thrombosed capillaries (“seeds”)
  • Common on hands and feet (plantar)
36
Q

Diagnosis of Verucca Vulgaris (Common Warts)

A

Clinical presentation

•15 Blade scrape off hyperkeratotic portion, thrombosed capillary can be visualized

37
Q

Treatment of Verucca Vulgaris (Common Warts)

A
  • 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

38
Q

Varicella (Chicken Pox)

A

Etiology: Varicella-Zoster virus (VZV), a herpes virus

  • Transmission: aerosolized droplets or direct contact with skin lesions
  • Highly contagious
  • Recurrence occurs
39
Q

Clinical Stages of Varicella (Chicken Pox)

A

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

40
Q

Diagnosis of Varicella (Chicken Pox)

A
  • Visualizing lesions in all three stages at the same time

* Tzanck smear shows multinucleated giant cells

41
Q

Complications of Varicella (Chicken Pox)

A
  • Group A strep with associated complications
  • Encephalitis and Reye syndrome uncommon
  • Largest complications seen in immunocompromised patients
42
Q

Treatment of Varicella (Chicken Pox)

A
  • Symptomatic treatment
  • Contagious until all lesions are crusted
  • Avoid pregnant females!(Congenital varicella syndrome)
  • Acyclovir used in immunosuppressed pts
  • Vaccination (Varivax)
43
Q

Herpes Zoster

A

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
44
Q

Clinical Presentation of Herpes Zoster

A

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

45
Q

Complications of Herpes Zoster

A

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

46
Q

Treatment of Herpes Zoster

A

•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
47
Q

Prevention of Herpes Zoster

A

Zostavax(2006) or Shingrix(2017)

•Both approved >50yo, Recommended for >60 by ACIP

48
Q

Herpes Simplex Virus (HSV)

A

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

49
Q

HSV - I

A

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
50
Q

HSV - II

A

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

51
Q

Pathogenesis of Herpes Simplex Virus (HSV)

A
  • 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.
52
Q

Clinical Presentation of Herpes Simplex Virus (HSV)

A

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
53
Q

Diagnosis of Herpes Simplex Virus (HSV)

A 
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
54
Q

Complications of Herpes Simplex Virus (HSV)

A
  • Erythema multiforme
  • Eczema herpaticum
  • Recurrent aseptic meningitis
55
Q

Treatment of Herpes Simplex Virus (HSV)

A

•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

56
Q

Epidermal Inclusion Cyst

A
  • Most common cutaneous cyst
  • Also called: epidermoid cyst
Clinical Presentation:
•Soft, mobile nodule
•Fluctuant
•Often central punctum
•Infected: erythema, inflammation, very painful
57
Q

Treatment of Epidermal Inclusion Cyst

A
  • Nothing: May respond spontaneously but recur often
  • Uninfected: Kenalog injection, I&D, excision
  • Infected: I&D, Oral antibiotics may be needed
58
Q

Lipoma

A
  • 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

59
Q

Treatment of Lipoma

A

•Surgical removal: cosmesis, compression of adjacent structures, diagnosis is questionable
•Malignant concerns with larger deeper tumors and
rapid growth

60
Q

Sarcoma

A

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

Clin Med I (5 decks)

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