Transcript Slide 1

Visual Diagnosis
aka: 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 to very 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
How do you treat LCV in
the ER?
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
Thanks!