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Dermatology Emergencies- Belazarian Flashcards

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1
Q

Describe DRESS and the common drugs associated with this syndrome.

A

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
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2
Q

Describe the Clinical Picture of DRESS

A
  • Onset 4-6 weeks after starting drug
  • Fever initially
  • EDEMA of the face (hallmark)
  • Eosinophilia
  • Liver
  • Joints
  • Any major organ system
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3
Q

Describe the treatment of DRESS

A
  • Discontinue Offending drug
  • Corticosteroids

Note: Death usually due to fulminant hepatitis.

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4
Q

Describe Erythema Multiforme

A
  • 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

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5
Q

Describe the etiology of Erythema Multiform

A
  1. Herpes Simplex (1-3 weeks before)
    - may or may not be clinically evident
  2. Mycoplasma
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6
Q

Describe the treatment of Erythema Multiforme

A

Prevention of Herpes Outbreak

  • Sunscreen
  • Antivirals (Acyclovir, Valacyclovir)
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7
Q

Describe Steven Johnson Syndrome

A
  • AKA Erythema Multiform major
  • < 10% of total BSA involved
  • 2 or more mucous membranes involved
  • Atypical targets (not 3 zones)
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8
Q

Describe the Clinical Features of Steven Johnson Syndrome

A

GFR PPD

  • Gritty eyes
  • Fever/ Flu-like prodrome
  • Red Tender skin –> Sloughing
  • Photosensitivity
  • Painful urination and bowel movements
  • Difficulty swallowing or eating
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9
Q

Describe Toxic Epidermal Necrolysis

A
  • > 30% of total BSA involved

- Target lesions are not common.

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10
Q

Describe the Clinical features of Toxic Epidermal Necrolysis

A

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

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11
Q

List the causes of SJS and TEN

A
  • Trimethroprim-Sulfamethoxazole
  • Antibiotics
  • Anticonvulsants
  • Allopurinol
  • NSAIDS
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12
Q

Discuss the management of SJS and TEN

A
  • Withdraw offending drug
  • Burn Unit
  • Fluids/electrolytes
  • Temperature

-IV Steroids and/or Immunoglobulins (Controversial)

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13
Q

What is the mortality rate for SJS and TEN

A
  • 5%

- 30%

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14
Q

Describe Exfoliative Erythroderma

A
  • Many Etiologies
  • Redness and Scaling over >90% of the body
  • Older patients
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15
Q

Describe the clinical features of Exfoliative Erythroderma

A
  • Pruritis and Fatigue
  • Redness and scaling
  • Dermatopathic lymphadenopathy
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16
Q

Describe some of the associated etiologies of Exfoliative Erythroderma

A

AC IPAD

Atopic Dermatitis
Cutaneous T cell Lymphompa (mycosis fungoides)
Idiopathic
Psoriasis 
Allergic Contact Dermatitis
Drug Reaction
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17
Q

Name the emergency sequelae of Exfoliative Erythroderma

A

HD PIC

  • Heat fluid loss through skin –> Temperature instability
  • Dehydration
  • Protein loss
  • Infections
  • Congestive Heart failure (High output)
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18
Q

Describe the management of Exfoliative Erythroderma

A
  • Stop the offending drug
  • Treat underlying skin condition
  • Supportive Therapy: Temp, Fluids, hemodynamics
  • Topical Steroids
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19
Q

What is the mortality range for Exfoliative Erythroderma?-

A
  • 4.6 to 64%

- Relapse is common

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20
Q

Name the causative agent for Meningococcemia and describe the common setting that outbreaks are observed

A
  • Neisseria Meningitides
  • Schools
  • Military Barracks

Note: Transmission is through inhalation of aerosol droplets.

  • Nasopharyngeal infection
  • Hematogenous dissemination
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21
Q

Describe the pathophysiology of meningococcemia

A

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
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22
Q

Describe the risk factors for development of meningococemia

A
  • Young age
  • Asplenia
  • Immunoglobulin deficiency
  • Late complement deficiency (C5-C9)
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23
Q

Describe the clinical features of Meningococemia

A
  • Petechiae
  • Angular or Stellate lesions (with GUNMETAL grey center)
  • Pupura Fulminans
  • Fever Chills and Hypotension
  • Meningeal signs (80% develop meningitis)
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24
Q

Describe the Diagnosis and Treatment of Meningococcemia

A

Dx:

  • CSF and Blood Culture
  • Gram stain of Pustules show Gm-negative Diplococci

Rx:

  • Ceftriaxone
  • Ampicillin
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25
1. What is the causative agent for Rocky Mountain Spotted Fever 2. What is the tick species that serves as the vector? 3. What state is it common?
- Rickettsia Rickettsii - Dermacentor tick - Common in North Carolina - Rarely in the Rocky Mountain states
26
Describe the Pathogenesis of Rickettsia Rickettsi
- Replicates in endothelium of Dermis - Spreads hematogenously and attaches to endothelial cell - Results in Vascular/ tissue injury
27
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
28
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
29
What is the Classic Rocky Mountain Spotted Fever Triad?
- Fever - Rash - Headache
30
What is the Gold Standard Rx for Rocky Mountain Spotted Fever?
Doxycycline Note: We use the Dox to kill Dermacentor
31
What is the pathogen implicated in Toxic Shock Syndrome? What is the alternate (and more common) pathogen implicated in another variation of this syndrome?
1. Staph Aureus 2. Strep Pyogenes causes Streptococcal Toxic Shock Syndrome - More common!
32
Describe the pathogenesis of s. aureus in TSS
There is a massive release of cytokines due to bacterial toxins acting as Superantigens.
33
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.
34
Describe the treatment for TSS
- IV fluids and vasopressors | - Penicillinase resistant antibiotics
35
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%
36
What predisposes young girls to Staph aureus TSS?
Tampon Use
37
In what population subtypes do we see disseminated HSV
- Immunocompromised (HIV) - Newborns - Pregnant - Malignancies
38
Patients with what skin condition are at risk for developing a viral associated condition?
Patients with ECZEMA are at risk for developing: ECZEMA HERPETICUM
39
What is the clinical appearance of disseminated HSV?
Clustered Erosions
40
What do we use to diagnose Disseminated HSV?
To detect HSV, we use TDV - Tzanck smear - Direct Fluorescent antibody (DFA) - Viral Culture
41
What is the Rx for Disseminated HSV?
IV Acyclovir
42
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.
43
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.
44
Describe the clinical picture for Calciphylaxis
Sudden onset of intense PAIN from necrotic/ indurated lesions. Common locations: Thighs Butt Lower abdomen
45
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%
46
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
47
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
48
What is Erythema Nodosum?
A delayed type hypersensitivity response to a variety of different antigenic stimuli
49
Where in the body are we likely to see the clinical manifestations of Erythema Nodosum?
- Lower Legs, bilaterally. | - Anterior is common
50
What are some of the common trigger of Erythema Nodosum?
``` Sarcoidosis TB UC Crohn's Kontraceptive Oral pills ```
51
Structurally, what part of the skin is afflicted in Erythema Nodosum?
Inflammation Deep into the fat layer | -results in the firm nodules
52
Describe the category of pathology of Erythema Nodosum
-Panniculitis (inflammation of the subcutaneous fat)
53
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
54
What is the Rx for Erythema Nodosum?
Treat underlying disorder. - NSAIDS - Bed rest
55
What is Herpes Zoster?
- AKA Shingles - Recurrent infection with Vericella Zoster - Reactivation of latent virus in the sensory ganglia - Trunk Location - Dermatomal
56
What type of person gets Herpes Zoster?
- Elderly | - Immunocompromised
57
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.
58
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
59
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)
60
Hemorrhagic Crusting is classic for what condition?
Steven Johnson's
61
How is Steven Johnson's different from TEN?
Body surface area afflicted. | -Less than 10% vs Greater than 30%
62
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

Dermatology (7 decks)

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