4 - Serious Stuff

Question 1

What is a “drug eruption”?

Answer 1

A derm thing caused by drugs

Rash

Pruritus

Could be basically any patient sensitive to any compound in any drug

Question 2

Describe the morphology of drug eruption:

Answer 2

Maculopapular is the MC presentation

Could also be urticarial

Or just skin flushing with pruritus

Basically, could be anything

Question 3

What is the MC type of drug eruption?

Answer 3

Exanthems (maculopapular)

May be indistinguishable from viral exanthem

Goes away rapidly when you stop taking the drug

Usually spares the face

Question 4

What is the MC site of a fixed drug eruption?

Answer 4

The glans penis

But can occur anywhere

Question 5

Describe a fixed drug eruption

Answer 5

Single or multiple, round, sharply demarcated, dusky red plaques

Appear soon after drug exposure

At the same site every time

Often blister

Question 6

How do we treat drug eruption?

Answer 6

Stop the med (duh)

Give antihistamines

PO or topical class III-IV steroids

Be alert for development of anaphylaxis

Question 7

How will a patient with urticaria appear?

Answer 7

Itchy

Uncomfortable

Possibly short of breath, difficulty swallowing, or itchy mouth/throat (ominous signs)

Question 8

Morphology of urticaria?

Answer 8

Hives (wheal)

Firm, edematous plaque

Faint pink with central pallor

Orange peel appearance (2/2 follicular accentuation)

Transient (about 24hrs) then fade and recur

Question 9

What is the etiology of urticaria?

Answer 9

Release of histamine from mast cells

Immediate hypersensitivity reaction

Question 10

Causes of physical urticaria?

Answer 10

Dermatographism

Pressure (belts, constrictive jewelry)

Solar

Cold/heat

Aquagenic

Cholinergic (exercise, emotion)

Usually only lasts 30-60 mins

Question 11

Acute vs chronic urticaria - what’s the cutoff?

Answer 11

6 weeks

Question 12

Txt of acute urticaria

Answer 12

IM or PO diphenhydramine

PO steroids

If anaphylaxis - epinephrine SQ (1:1000)

Question 13

Txt for chronic urticaria:

Answer 13

Antihistamine, 2nd gen (i.e. cetirizine)

H2 blockers (i.e. ranitidine)

PO steroids (short-term)

Restrictive diet

Question 14

What is angioedema?

Answer 14

Localized, dramatic and rapid swelling of the subcutaneous tissue

Burning and painful swelling

Can happen anywhere - commonly the lips, eyes, tongue, trunk, genitalia, hands

Can involve the GI and respiratory tracts

MAY LEAD TO ANAPHYLAXIS

Question 15

Txt of angioedema

Answer 15

Potentially aggressive management (if severe anaphylaxis develops)(have epi ready, if rapid swelling of resp tract may need to intubate before that shit closes up)

IM or PO diphenhydramine

PO steroids

Question 16

What is the MC small vessel necrotizing vasculitis?

Answer 16

Leukocytoclastic (hypersensitivity) vasculitis

Question 17

Describe Leukocytoclastic (hypersensitivity) vasculitis

Answer 17

Prodrome of fever, malaise, myalgia, arthralgia

Lesions itch and are painful

Appear in crops, last 1-4 weeks

Can spread to multiple organs besides skin

Question 18

Morphology of Leukocytoclastic (hypersensitivity) vasculitis

Answer 18

Inflammation of blood vessel walls cause leakage of RBC’s

Vesicles and points of necrosis

Starts small and continues to increase in size, may coalesce

Palpable purpura

Heals with scars and hyperpigmentation

Question 19

Distribution of Leukocytoclastic (hypersensitivity) vasculitis

Answer 19

Any dependent area (due to increased hydrostatic pressure and extravasation of RBC’s

Lower legs, arms, back and sacrum if bed-bound

Question 20

Etiology of Leukocytoclastic (hypersensitivity) vasculitis

Answer 20

Immune-complex deposition on vessel walls, inflammatory response damages walls

Underlying cause could be: viral hepatitis, strep, UTI, drugs, systemic dz, malignancy…soooo again, anything…starting to see a pattern with derm: anything is anything

Question 21

How do we manage Leukocytoclastic (hypersensitivity) vasculitis

Answer 21

Look for a cause

Also, look for systemic involvement (renal, GI, etc)

Txt the underlying condition

Topical steroids / abx cream

Question 22

50% of Leukocytoclastic (hypersensitivity) vasculitis patients will have:

Answer 22

Hematuria

Question 23

What is Henoch-Schonlein Purpura?

Answer 23

An acute Leukocytoclastic (hypersensitivity) vasculitis that occurs mainly in kids (2-10 yrs)

MC systemic vasculitis in kids

Palpable purpura on the legs and buttocks

Athralgias, abdominal pain

Question 24

Labs for HSP?

Answer 24

Nothing specific - ESR, serum complement, and IgA are all up

Question 25

Morphology of HSP

Answer 25

Palpable purpura on legs and butt Trunk or normally spared Starts as hives, then class Leukocytoclastic lesions within 48 hrs 2-10mm in diameter and appear in crops among coalescent ecchymosis and pinpoint petechiae Fade in several days leaving brown macules

Question 26

What causes HSP?

Answer 26

It’s a hypersensitivity reaction May be preceded by an URI by 1-3 weeks Strep with IgA deposits around the vessels

Question 27

How do we manage HSP?

Answer 27

It’s a self-limiting dz Watch for GI bleed and blood loss NSAIDs and PO steroids Occasionally dapsone or plasmapheresis

Question 28

Long-term prognosis for HSP directly dependent on:

Answer 28

The severity of renal involvement

Question 29

What’s the common patient profile for erythema multiforme?

Answer 29

Young adults (age 20-40) Fever, malaise, burning lesions Preceding URI or HSV infx (or mycoplasma pneumoniae)

Question 30

Morphology of erythema multiforme?

Answer 30

Urticarial papules Target lesion or vesicles/bullae (red macule with central color change, coalesce to involve large areas, recur in crops for 2-3 weeks)

Question 31

Distribution of EM

Answer 31

Back of hands Palms Soles Extensor limbs May be generalized Mucous membranes in up to 70% of cases

Question 32

Etiology of EM?

Answer 32

Preceding URI or HSV Immune complex dz - damages vasculature, causes tissue necrosis

Question 33

Management of EM:

Answer 33

Symptomatic relief, otherwise no tx if mild Prednisone with taper or 1-3 weeks If HSV-induced, oral antivirals

Question 34

What’s the patient profile for SJS?

Answer 34

Very sick and in pain Any age, but more common in young children and young adults Preceded by URI with high fever and malaise OR induced by meds for seizure, gout, abx

Question 35

Morphology of SJS:

Answer 35

Initial - fever, stinging eyes, pain with swallowing - 1-3 days prior to cutaneous sxs Flat, atypical targets or pruritic macules, widespread on the trunk first, then neck, face, and proximal upper extremities Palms/soles early - maybe Bullous lesions Ulcerative lesions with hemorrhagic crusts appear on the mucosal surfaces

Question 36

Etiology of SJS:

Answer 36

Direct toxic effect from seizure drugs Viral URI Mycoplasma pneumonia

Question 37

Management of SJS:

Answer 37

Steroids controversial Control itching and pain IV fluids (really important) If severe -> burn unit Ophthalmology consult ABX if secondary infx NG feed if severe throat pain Foley if severe dysuria

Question 38

Complications of SJS:

Answer 38

Sloughing of upper and lower respiratory tract Blindness 2/2 corneal lesions

Question 39

Toxic epidermal necrolysis - presentation

Answer 39

Looks like SJS initially but the big difference is that TEN then progresses to the skin peeling off at the dermoepidermal junction Any age Prodrome - fever (MC), HA, sore throat (associated URI) Sudden onset red, tender skin High mortality

Question 40

Morphology of TEN:

Answer 40

Generalized red macular “sunburn” look Diffuse, hot erythema Within hours, skin is painful Skin peels of (Nikolsky sign)(bad sign) Desquamation Vesicles and large bullae appear Scalp is spared

Question 41

Mucous membrane involvement in TEN:

Answer 41

Inflammation, blistering, erosion of mucosal surfaces Especially the oropharynx GI tract usually spared Vaginal tract epithelium blisters and erodes Eyes - purulent conjunctivitis, ulceration, erosion

Question 42

MCC of TEN:

Answer 42

ABX Followed by anticonvulsants, NSAIDs

Question 43

Management of TEN:

Answer 43

Burn unit ASAP NO STEROIDS Cyclosporine A Cyclophosphamide Plasma exchange IVIG

Question 44

What is the MCC of death in the setting of TEN?

Answer 44

Infection (hence the need for burn unit care - they are Jedi’s with avoiding infection)

Question 45

What is staphylococcus scaled skin syndrome? (SSSS)

Answer 45

A blistering disease caused by s. aureus exfoliative toxins

Question 46

Who gets SSSS?

Answer 46

Newborns (Ritter’s dz), infants, small children Staph infection with negative skin culture Common sites for positive cultures: ears, tonsils, sinuses, conjunctiva

Question 47

Morphology of SSSS:

Answer 47

Generalized sunburn-like erythema, sandpaper-like rash Very tender (unlike scarlet fever) Clown facies - crusting around mouth Exfoliation Total body distribution

Question 48

Etiology of SSSS:

Answer 48

2/2 coag (+) s. aureus toxin Same organism as bullous impetigo The kid’s immature kidney’s can’t clear toxin effectively

Question 49

Management of SSSS:

Answer 49

Low mortality Anti-staph meds (diclox/ceph) No corticosteroids (interfere’s with host immunity) Avoid touching skin

Question 50

How to differentiate TEN from SSSS

Answer 50

Do a frozen section Split is SSSS is more superficial than in TEN

Question 51

Mucocutaneous lymph node syndrome is AKA:

Answer 51

Kawasaki’s

Question 52

Patient profile for Kawasaki’s

Answer 52

2 or 3 year-old, previously healthy, fever 101-104 (unresponsive to antipyretics) Cervical adenopathy Rash Oral/mucous membrane changes

Question 53

Morphology of Kawasaki’s

Answer 53

Acute phase - fever 7-14 days and resolves. Conjunctival injection, strawberry tongue, tender edema of palms/soles (peels after 10 days), diffuse maculopapular rash Subacute phase - end of fever to 25 days -> desquamation of fingers, toes, arthralgias, thrombocytosis Convalescent phase - begins when clinical signs disappear through normalization of ESR (about 7 weeks after onset)

Question 54

Distribution of Kawasaki’s:

Answer 54

Conjunctival injection Strawberry tongue Palms/soles -> red, swollen, tender Diffuse urticaria and maculopapular eruption (desquamation in 5-7 days) Diaper dermatitis is common Cervical lymphadenopathy

Question 55

Etiology of Kawasaki?

Answer 55

We don’t know.

Question 56

Management of Kawasaki’s

Answer 56

Watch for cardiac abnormalities High-dose IVIG ASA

Question 57

Labs in Kawasaki’s?

Answer 57

WBC can be over 20K Elevated ESR/CRP Thrombocytosis

Question 58

What’s the patient profile for toxic shock syndrome (TSS)?

Answer 58

``` Post-partum Post-C-section Nasal packing and nasal staph carriage Diaphragm use Post-op (most cases) 1970’s super awesome mega-absorbent tampons ```

Question 59

What’s the morphology of TSS?

Answer 59

Diffuse, scarlet fever-like rash Macular, erythematous, looks like a sunburn Desquamation of palms/soles Vaginal hyperemia and tenderness Conjunctival injection Strawberry tongue

Question 60

Diagnostic criteria for TSS:

Answer 60

Fever > 102 Diffuse, erythematous, macular rash Mucous membrane involvement HOTN (SBP<90mmHg) Multi-system involvement

Question 61

What causes TSS:

Answer 61

Coag (+) staph toxin Localized infection with systemic toxin spread

Question 62

How do we manage TSS?

Answer 62

Beta-lactamase-resistant abx (oxacillin, nafcillin, cefoxitin, vancomycin/clindamycin) I and D abscess Remove tampon Increased hydration Maintain BP with pressors if necessary Mortality 5-10% (higher in dudes)

Question 63

Dont use regular tampons

Answer 63

Because now there is new all natural Cherokee hair tampons.