2014-12-05-Dermatoconjunctivitis-Lara
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Transcript 2014-12-05-Dermatoconjunctivitis-Lara
Grand Rounds Conference
Lara Rosenwasser Newman, MD
University of Louisville
Department of Ophthalmology and Visual Sciences
December 5, 2014
Subjective
CC: Red eyes and eyelids, eyes burning x 2 days
HPI: 51 yo WM, inpt for dyspnea, dysphagia, who
began to have burning in his eyes, red eyes, and
redness and burning of the skin around the eyes,
progressively worsening over 2 days.
Had upper endoscopy 2 days prior, awaiting path.
Felt that placing cold washcloth over eyes
helped. Primary team had placed on cipro gtts
x1 day.
History
PMHx:
Barrett’s esophagus, esophageal cancer, COPD
per pt Hep C treated w/IFN, in remission since
2004 or 2005
PSHx:
Multiple upper endoscopies, Nissen fundoplication
POHx:
Presbyopia
Medications:
At home: Paxil, Prilosec, Singulair, albuterol inhaler
History Continued
Medications as inpatient:
Dilaudid, morphine, Zofran
1x doses atropine/hyoscyamine/PB/scopolamine,
GI cocktail, hydroxide/Mg hydroxide/simethicone
Lovenox, hydromorphone, lidocaine morphine
Pantoprazole, Paxil
Cipro 2 gtts OU q4h while awake
Rocephin 1g daily
Flu shot
Clinical Exam
OD
VA (near, +2.00s): 20/25
OS
20/20
Pupils:
2.51.5
2.51.5
(-) rAPD
IOP (tonopen): 18mmHg
0
EOM:
0
0
0
18mmHg
0
0
0
0
Clinical Exam
PLE:
External/Lids
Conjunctiva/Sclera
Cornea
Anterior Chamber
Iris
Lens
Vitreous
Erythema lower>upper lids, red-racooneyes appearance, skin rough/sandpapery,
mild edema, not indurated
Severe injected OU, did not blanche w/
phenylephrine, mucoid discharge
diffuse fine SPEs on fluorescein
Formed OU
Normal OU
Clear OU
Normal OU
DFE: ON pink & sharp OU, M/V/P WNL
External Appearance
Exam continued
Approx 1 cm excoriated plaque on posterior left
neck, no other skin lesions
Afebrile, stable vitals
Mucoid to purulent appearing discharge, sent for
aerobic and anaerobic cultures
Final results: negative
Assessment
51 yo WM w/dysphagia, chest pain,
dyspnea, presenting with acute
dermatoblepharoconjunctivitis.
Differential Considerations
Contact dermatoconjunctivitis
Detergent hospital uses for washcloths?
Dermatomyositis
Preseptal cellulitis
Plan
Discontinue Cipro gtts
Aggressive lubrication w/preservative-free
artificial tears q2-4 hrs
Follow-up cultures (negative)
Follow-up
Resolved over next several days
Pt was discharged days later
Surg path from upper endoscopy: Barrett’s,
otherwise benign
Symptoms attributed to gastroparesis,
gastritis/esophagitis
Now in hospital again for dyspnea, dysphagia,
and chest pain
Review of 215 pts who presented for eyelid dermatitis in
a 42 month period
165 allergic contact dermatitis (personal care products, metals)
9 protein contact dermatitis (no positive patch test)
35 atopic eczema (33 of these also had contact allergies)
35 psoriasis or seborrheic dermatitis or both
5 rosacea or periorbital dermatitis
2 dermatomyositis
Guin JD. Eyelid dermatitis: a report of 215 patients. Contact Dermatitis. 2004 Feb;50(2):87-90. PubMed PMID: 15128319.
Contact dermatitis
Most common eruption of eyelid
Can involve lids & eyes
Unilateral or symmetrical
Pruritic, scaling erythematous eruption of lid(s)
May see periorbital edema, blepharitis, conjunctivitis
Watery discharge, papillary or follicular conj rxn
Allergic (pruritus) or irritant (burning/stinging)
Can be very difficult to distinguish between
3 top causes: cosmetics, topical ophthalmic meds, CL
solutions
Provocative substances
Drugs
Cosmetics/personal care products
including nail polish, hand soap
Preservatives
Dyes
Plant resins
Heavy metals
Plastic or nickel in glasses
Contact dermatitis
Dx: patch testing, clinical picture
Tx: identify/eliminate offending allergen/irritant
Cool compresses
Topical corticosteroids
Oral antihistamines
Contact Dermatitis
Dermatomyositis
Systemic vascular disorder
Skin & muscle inflammation, acute or insidious
Atonic, weak, achy proximal muscle groups
Gottron’s papules = diagnostic
Flat-topped erythematous papules over knuckles
Scaly areas on backs of hands, knuckles, elbows, knees,
and nail changes (shininess, erythema)
Telangiectasia, skin rash in malar region, neck, shoulders,
upper chest, and back
Assoc w/breast, ovary, lung, pancreas, stomach, colon,
rectum CA & NHL (18-32% of DM pts)
Can have GI & respiratory involvement
Dermatomyositis
Etiology: unknown
Genetic susceptibility + exposure to environmental
agents or cancers immune activation/inflam
Injury to capillaries & myofibers
2 theories:
Induction of type 1 IFN-inducible gene products
Antibody & complement-mediated microangiopathy
AutoAbs incl myositis-specific Abs (MSAs)
Can be precipitated/caused by penicillins,
sulfonamides, and D-penicillamine
Dermatomyositis
Dx: muscle biopsy
Labs:
High transaminases, CK, aldolase, LDH
sometimes (+) ANA, anti-Jo-1, anti-Mi-2, RF
Tx: systemic corticosteroids, usually
w/satisfactory response in classic DMS
Less so in pts w/anti-Jo Abs
If steroids fail, cytotoxic agents (MTX, azathioprine)
and/or IVIG
Dermatomyositis Features
Credit: Ostler, HB, Maibach, HI, Hoke, AW, and Schwab, IR. Diseases of the Eye & Skin: A Color Atlas. Philadelphia, PA; Lippincott
Williams & Wilkins, 2004: 14-19 and 112-122.
DM – Ocular Findings
Heliotrope telangiectasias of eyelids =
characteristic
CONJ CHEMOSIS = COMMON
Can cause nonspecific conjunctivitis, rarely
pseudomembranous conjunctivitis
Dermatomyositis Features
Credit: Ostler, HB, Maibach, HI, Hoke, AW, and Schwab, IR. Diseases of the Eye & Skin: A Color Atlas. Philadelphia, PA; Lippincott
Williams & Wilkins, 2004: 14-19 and 112-122.
Dermatomyositis Features
Credit: Mannis, MJ, Macsai, MS, Huntley, AC. Eye and Skin Disease. Philadelphia, PA; Lippincott-Raven Publishers, 1996: 233-238.
DM – Ocular Findings
Nonspecific episcleritis or scleritis
Exophthalmos
Anterior uveitis
Retinopathy w/cotton wool spots
Late sequelae of pigmentary maculopathy &
optic atrophy
EOM paralysis and nystagmus
Rare but important: orbital polymyositis or
ocular myositis assoc w/giant-cell myocarditis
References
1.
2.
3.
4.
5.
6.
Park IK, Chun YS, Kim KG, Yang HK, Hwang JM. New clinical grading scales and objective
measurement for conjunctival injection. Invest Ophthalmol Vis Sci. 2013 Aug 5;54(8):524957. doi: 10.1167/iovs.12-10678. PubMed PMID: 23833063.
Ostler, HB, Maibach, HI, Hoke, AW, and Schwab, IR. Diseases of the Eye & Skin: A Color
Atlas. Philadelphia, PA; Lippincott Williams & Wilkins, 2004: 14-19 and 112-122.
Mannis, MJ, Macsai, MS, Huntley, AC. Eye and Skin Disease. Philadelphia, PA; LippincottRaven Publishers, 1996: 233-238.
Guin JD. Eyelid dermatitis: a report of 215 patients. Contact Dermatitis. 2004 Feb;50(2):8790. PubMed PMID: 15128319.
Ebert EC. Review article: the gastrointestinal complications of myositis. Aliment Pharmacol
Ther. 2010 Feb 1;31(3):359-65. doi: 10.1111/j.1365-2036.2009.04190.x. Epub 2009 Nov 3.
Review. PubMed PMID: 19886949.
Iaccarino L, Ghirardello A, Bettio S, Zen M, Gatto M, Punzi L, Doria A. The clinical features,
diagnosis and classification of dermatomyositis. J Autoimmun. 2014 Feb-Mar;48-49:122-7.
doi: 10.1016/j.jaut.2013.11.005. Epub 2014 Jan 24. Review. PubMed PMID: 24467910.
Dermatomyositis: Resp & GI
Dysphagia from involvement of muscles of tongue,
pharynx, & upper 1/3 of esophagus
Can get dysphagia for liquids and solids
Pharyngeal and upper esophageal involvement can
cause asphyxiation and/or aspiration
Nasal regurgitation characteristic nasal voice
Muscles of respiration and myocardium may
also be affected
Dermatomyositis can be associated with:
Crohn’s/UC (IBD)
Celiac (may respond to gluten-free diet)
Hep C virus
Primary biliary cirrhosis
Can develop during IFN tx of HCV
Usually resolves w/discontinuation of IFN
Myopathies can occur during tx w/PPIs
Mentions polymyositis & rhabdo