Visual Diagnosisaka: Enough Derm To Make You Squirm Gerard B. Martin MD Department of Emergency Medicine Henry Ford Hospital & Health Network
Format • Audience Participation • Present case with visual findings (rash, etc) or skin findings • Develop a differential Dx based on the data given • Discuss case and implication for management in the ER • Just like life, some are easy and some are hard • Example: • 74 yr old male with HPTN • Recently started on new BP medicine • What is his problem? • What are you going to do about it? Warning: You probably want to close your lap top
63 yr old female had biopsy of nose recently. Now complains of increasing redness and pruritis at the site and is spreading. Her dermatologist is out of town. What is this and what are you going to do about it?
55 yr old female with UC, s/p colectomy with colostomy presents abdominal pain. You notice this with peristomal ulcer. What is this? Is it related to her UC disease?
TEN: Look for • Irregular dusky red macules on trunk, face, palms/soles largely coalescing • Flaccid, fragile blisters • Mucosal involvement: • Eyes & mouth most common • May precede skin involvement by 1-3 days in 30% • Systemic involvement • Differential Diagnosis: • How will affect our management in the ER?
It’s Thanksgiving again…………Cousin Ethel saw you checking out Crazy Uncle Joe so after a couple of martini’s she pulls off her stockings and asks your opinion about this growth on her foot. She said it started about a month ago. What do you tell Cousin Ethel?
34 y/o female with intensely pruritic plaques on both lower legs • Patient states these have been present for months • Tends to be worse in the winter months • No response to Lotrimin (clotrimazole) What is this? What are you going to do about it?
36 yr old female with vaginal yeast infection treat with fluconazole (Diflucan). Patient developed this rash 1 day after Rx. Prior Hx of contact dermatitis in vulva after miconazole (Monistat) for vaginal candidiasis. What’s the problem?
TSS 21 yr old female w/ 1 day hx of diffuse erythematous rash. Started on trunk and spread to extremities. Complains of headache, vomiting, diarrhea. T= 39.5 C HR: 140 BP: 70/30 RR: 24 Diffuse macular erythroderma What is this? What are you going to do about it? HINT: she is menstruating
Toxic Shock Syndrome (TSS) • What is the etiology? • What are typical signs and symptoms? • What are derm findings?
Staph TSS • First identified in menstruating young white females using tampons in 1980’s but who gets it most commonly now? • What are risk factors?
Staph TSS • What are the CDC Diagnostic Criteria? • How do you treat Staph TSS?
60 yr old male with pruritic rash on forearm • Very pruritic • What is it?
30 yr old homeless alcoholic presents with weakness, malaise, petechiae on legs, and bleeding gums • What is it? • What’s the treatment? • HINT: James Lind, a British surgeon, published his experiences and studies on this problem many years ago
43 yr old female presents with fever, arthralgias. You notice the rash on her face. What is it? What are you going to do about it?
12 year with rash in antecubital fossa of arm. Pruritic but otherwise feeling well. Mother says the rash just started 2 days ago. • What’s your first question to the patient? • What is this and what do you treat it with? • HINT: Mom is OOT!
44 yr old male with itchy rash on his penis. He swears that he is not sexually active. • Is he telling the truth? • What is this? • Did he get it from a toilet seat?
45 yr old male with recent dx of seizure and CAD presents with rash that started on face and spread over body of the past 2 days. Has had some nausea & vomiting T: 38.5C P= 125 BP: 90/60 RR: 22 PE: Dark red erythematous rash with macules, papules & placques. Cervical & inguinal lymphadenopathy What is this and what are you going to do about it? HINT: Seizure and CAD were diagnosed about 2-3 weeks ago
DHS (Drug Hypersensitivity Syndrome) • Idosyncratic rxn: fever, rash, & internal organ involvement (most commonly hepatitis) • DRESS: Drug reaction w/ eosinophilia & systemic symptoms • Only 60—70% have eosinophilia • Onset: • 1-8 wks after starting drug • Rash- >80% of cases
Drugs associated with DHS • What drugs are associated with DHS? • What are three essential elements of Dx? • What are the most commonly involved organ systems besides skin?
DHS: Look for • Erythematous rash often described as morbilliform • Red- ranging from faint pink tovery dark red • Macules & papules in a symmetrical fashion • Starting at face & spreading downward • Lymphadenopathy- can be very impressive • Some will have urticarial plaques that may be Dx as EM • Others SJS with atypical target lesions, small blistering areas, & mucosal involement • Can evolve to TEN (>30% BSA covered with blisters)
6 y/o male with 3 day history of worsening eruption, had “cold sore” 1 week ago. Now has generalized rash. • What’s the diagnosis? • HINT: next slide
Close up of rash on arm • So what’s the diagnosis?
You are listening to the lungs of a 56 year old male with COPD and notice this on his upper back. The patient says it has been there for “a while.” What do you tell him? Does anything in particular worry you about this mole? This needs to come off yesterday…………
54 yr old woman presented with 2-day hx of painful, enlarging rash over her face, ears, breasts, & extremities. CBC revealed neutropenia & lymphopenia. Urine tox screen was positive for cocaine and opiates. What is this? Hint: Urine tox screen was positive for cocaine & opiates.
37 year old male with hx of lesions on LE’s and buttocks for past 2 days. Lesions are painful, pruritic and palpable. Patient is on no medications. What is this? How do you approach this case? Diascopy: non-blanching. Does that help?
Leukocytoclastic Vasculitis (LCV) • Cutaneous small vessel vasculitis • Heterogeneous grp disorders: uniformly characterized by purpuric or erythematous papules, vesicles, urticarial lesions or petechiae • End result of complex interplay of immune complex deposition, autoab production, complement activation, inflammatory cell activation, mast cell degranulation • Clinically different cutaneous features seen with medium to large vessel vasculitis • Subcutanoeus nodules • Retiform purpura • Ulcers • Livedo reticularis
LCV • What are some of the causes of LCV? • How do you know if it is a systemic vasculitis? • What is the prognosis?
Varients of LCV • Henoch-Schonlein Purpura • Acute onset 1-2 weeks after URI • <10 yrs in LE’s and buttocks • Fever, arthralgias, renal, & GI involvement • Can occur in adults • Urticarial Vasculitis: • Recurrent painful eruptions that last >24 hrs w or w/o angioedema • Common: fever, malaise, arthralgias, myalgias, • SLE, Sjogren’s, Viral
36 yr old with hx of TIA c/o intensely pruritic rash on legs an arms Care to venture a guess as to etiology and treatment?
Same case- rash on arm Now what do you think?
26 yr old man w/ 5 day hx of cough, fever, & SOB. He had a vesicular rash that had started 3 days before the respiratory sxs began. Skin examination revealed a polymorphic rash with vesicles, pustules, and crusty lesions. CXR showed multiple small nodules in both lungs. What is this? What are you going to do about it?
21 yr old male presents with rash on chest on second day of spring break in Mexico • Very pruritic • Clusters of confluent papules. • Involved dorsum of hands but spared face • He’s concerned it may be from the co-ed he met last night. • What is it? • HINT: PMLE
If you remember nothing else tonite, try to remember this…… • Rash w/mucosal lesions, blisters or desquamation often due to • serious soft tissue infections • drug eruptions • immune disorders • Purpura = blood leaking from vessels into the skin. • DO NOT blanch with pressure • Purpura < 3mm = Petechiae • Nonpalpable purpura = usually coagulation defects (often platelet abnormalities) • Palpable purpura often but not always sign of vasculitis
Reticulated Purpura • Lacy like • More serious that few purpuric lesions on legs • Implies large vessel disease • Antiphospholipid antibodies • Rheumatoid factor • Cholesterol • Cryoglobulins