Transcript 2016 Derm Case Studiesx

CASE STUDIES
IN DERMATOLOGY
2016 NURSING 870
CASE
• J.T., A 32 YEAR OLD CAUCASIAN MALE PRESENTS TO HIS PRIMARY
CARE PROVIDER WITH C/O A “SPIDER BITE.” THE PATIENT NOTED A
REDDENED, PAINFUL AREA UNDER HIS RIGHT ARM X 2 DAYS AGO.
HISTORY
• WHAT QUESTIONS SHOULD YOU ASK IN THE HISTORY AND ROS?
HISTORY
• PATIENT NOTED A PAINFUL LUMP IN HIS RIGHT AXILLA X 2 DAYS AGO.
THE LUMP APPEARS TO BE GETTING LARGER AND IS NOW PAINFUL
AND RED. HE DOES NOT RECALL BEING BIT BY AN INSECT. THERE ARE
NOT OTHER SKIN LESIONS AND HE HAS NEVER HAD A LUMP LIKE THIS
IN THE PAST. THERE HAVE BEEN NO FEVERS, CHILLS, SWEATS, RASH,
JOINT PAIN.
OTHER HISTORY
• JT HAS NO MEDICAL HISTORY, TAKES NO DAILY MEDICATIONS OR
SUPPLEMENTS AND HAS NO KNOWN ALLERGIES TO MEDICATIONS.
• SMOKES 1 PPD, DRINKS ALCOHOL ON WEEKENDS, DOES NOT USE
ILLICIT DRUGS
• LIVES WITH WIFE AND 2 YOUNG CHILDREN; AGES 3 AND 5.
• WORKS AS A AN ELECTRICIAN
ROS
• ALL NEGATIVE IN THE ROS
PE
• WHAT COMPONENT OF THE PE WOULD YOU PERFORM?
PE
• VS: 99-88-16, BP 132/82
• SKIN: R AXILLA WITH 4 CM ERYTHEMATOUS LESION, WARM, TENDER.
CENTER OF LESION IS RAISED, FLUCTUANT AND POINTING. NO
DRAINAGE IS PRESENT
• ALL OTHER SYSTEMS WITH NORMAL FINDINGS
PE
DIFFERENTIAL
• WHAT’S YOUR DIFFERENTIAL AT THIS POINT?
DIFFERENTIAL
• CELLULITIS
• ABSCESS
• INSECT BITE
WHAT’S THE TREATMENT?
TREATMENT
• I & D IF ABSCESS
• POSSIBLE ANTIBIOTICS
• HOW IS THE ANTIBIOTIC SELECTED?
• WHAT’S THE MOST LIKELY ORGANISM?
Purulent skin and soft tissue infections (SSTIs).
Dennis L. Stevens et al. Clin Infect Dis. 2014;cid.ciu296
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For Permissions, please e-mail:
[email protected].
TREATMENT
IDSA ANTIBIOTIC SUGGESTIONS BY ORGANISM:
• GROUP A STREP AND /OR MSSA (METHICILLIN SENS. STAPH AUREUS)
CEPHALEXIN 500 MG PO TID X 10 DAYS
OR CLINDAMYCIN 300 MG PO TID X 10 DAYS
• MRSA:
TMP/SMX (BACTRIM DS) 1 PO BID X 10 DAYS
OR DOXYCYCLINE 100 MG PO BID X 10 DAYS
(PLEASE AVOID CLINDA ALONE AS WE ARE SEEING MRSA RESISTANCE. CAN BE USED
AS ADD-ON).
• TO COVER BOTH STREP AND MRSA:
KEFLEX 500 MG PO TID X 10 DAYS (STREP COVERAGE)
PLUS BACTRIM DS OR DOXYCYCLINE
TREATMENT
• FOLLOW-UP:
• 24-48 HOURS FOR IMPROVEMENT
• PATIENT EDUCATION
• RETURN IF FEVER, EXTENSION OF REDNESS, RED STREAKS
• COMPLETE ANTIBIOTICS
• PREVENTION OF SPREAD
CELLULITIS
• SKIN INFECTION OF DERMIS AND SUBQ TISSUES
• MOST COMMONLY R/T GROUP B STREP AND STAPH AUREUS (NORMAL
IMMUNE STATUS)
• GRAM – OR FUNGAL IN IMMUNE COMPROMISED
• FACIAL CELLULITIS: H. FLU AND STREP PNEUMONIAE
• OTHERS: CONSIDER IF PUNCTURE WOUND, EXPOSURE TO FRESH WATER
OR SALT WATER
CELLULITIS
CELLULITIS: RISK FACTORS
• CRACKS IN SKIN
• HX OF PVD
• INJURY OR TRAUMA TO SKIN
• DIABETES
• USE OR CORTICOSTEROIDS OR IMMUNE SUPPRESSANTS
• WOUND FROM RECENT SURGERY
CELLULITIS: SYMPTOMS
• FEVER
• SIGNS OF INFECTION
• PAIN OR TENDERNESS IN THE AREA OF THE RASH OR LESION
• SKIN REDNESS OR INFLAMMATION
• SKIN LESION OR RASH
• SHARP BORDERS
• MAY GROW QUICKLY IN FIRST 24 HRS
CELLULITIS SYMPTOMS
• SKIN MAY APPEAR STRETCHED OR TIGHT
• WARMTH OVER AREA OF REDNESS
• N/V
• MAY BE JOINT STIFFNESS IF OVER JOINT
COMPLICATIONS
• LYMPHANGITIS
• ABSCESS
• GANGRENOUS CELLULITIS
• NECROTIZING FASCIITIS
• BACTEREMIA
• SEPSIS
CELLULITIS: DIAGNOSTIC TESTS
• CBC
• BLOOD CULTURE
• CULTURE ANY ABSCESS OR DRAINAGE
CELLULITIS TREATMENT: ANTIBIOTICS
• BASED ON APPEARANCE
• IF NO
• EMPIRIC COVERAGE FOR STREP AND STAPH AUREUS SHOULD BE
PROVIDED
• CONSIDER TETANUS STATUS
ANTIBIOTICS
IDSA ANTIBIOTIC SUGGESTIONS BY ORGANISM:
• GROUP A STREP AND /OR MSSA (METHICILLIN SENS. STAPH AUREUS)
CEPHALEXIN 500 MG PO TID X 10 DAYS
OR CLINDAMYCIN 300 MG PO TID X 10 DAYS
• MRSA:
TMP/SMX (BACTRIM DS) 1 PO BID X 10 DAYS
OR DOXYCYCLINE 100 MG PO BID X 10 DAYS
(PLEASE AVOID CLINDA ALONE AS WE ARE SEEING MRSA RESISTANCE. CAN BE
USED AS ADD-ON).
• TO COVER BOTH STREP AND MRSA:
KEFLEX 500 MG PO TID X 10 DAYS (STREP COVERAGE)
PLUS BACTRIM DS OR DOXYCYCLINE
CELLULITIS TREATMENT
• HOSPITALIZATION IF:
• SEPSIS
• FAILURE TO RESPOND TO TREATMENT
• IMMUNE COMPROMISED STATE
• PERIORBITAL CELLULITIS
SKIN ABSCESS
• LOCAL ACCUMULATION OF PUS/DEBRIS
• MOST COMMONLY OCCUR IN AXILLAE, GROIN
• CONSIDER IF ANY FOREIGN BODY, IV DRUG ABUSE
ABSCESS TREATMENT
• I & D ALONE FOR SIMPLE ABSCESS
• ANTIBIOTIC IF:
• GENERALLY > 5 CM
• MULTIPLE SITES
• RAPID PROGRESSION OR ASSOC. CELLULITIS
• SYSTEMIC ILLNESS
• IMMUNOSUPPRESSION
• EXTREMES OF AGE
• FAILURE TO RESPOND TO I & D ALONE
• AREA WHERE I & D DIFFICULT
ABSCESS: ANTIBIOTICS
• SAME AS BEFORE…
ABSCESS ANTIBIOTICS
• 5-10 DAYS OF TREATMENT
• OTHER SELECTIONS FOR HOSPITALIZED PATIENTS AND PEDIATRIC
PATIENTS
• CONSIDER TETANUS STATUS
RECURRENT MRSA?
DECOLONIZE!
WASH WITH HIBICLENS SOAP IN SHOWER FOR 7 DAYS
MUPIRICIN OINTMENT TO NARES BID X 5 DAYS
CLEAN HIGH-CONTACT SURFACES
AVOID SHARING PERSONAL ITEMS (TOWELS, RAZORS, ETC)
BITES
• MAY OR MAY NOT BE EVIDENT
• TREATMENT IS FOR CURRENT ABSCESS OR CELLULITIS AND RABIES FOR
ANIMAL BITES
SPECIAL CONSIDERATIONS
• DOG BITE
• CONSIDER STAPH, STREP, EIKENELLA, OTHERS
• CAT BITE
• CONSIDER PASTEURELLA, OTHERS
• HUMAN BITE
ANTIBIOTICS
• COVER STAPH, STREP, ANAEROBES, PASTEURELLA
• IF PROPHYLACTIC TREATMENT FOR 3-5 DAYS
• IF INFECTION TREATMENT FOR 10 DAYS OR LONGER
• FIRST LINE TREATMENT: AMOXICILLIN-CLAVULANATE
OTHER CONSIDERATIONS
• FOR ANIMAL BITES CONSIDER TETANUS STATUS AND POTENTIAL FOR
RABIES TREATMENT FOR BITES BY DOGS AND CATS WHOSE RABIES
STATUS CAN NOT BE OBTAINED, OR IN FOXES, BATS, RACCOONS, OR
SKUNKS IN THE U.S.
HIDRADENITIS SUPPURATIVA
• RECURRENT INFLAMMATORY DISORDER OF SKIN CONTAINING
APOCRINE (SWEAT) GLANDS
• TYPICALLY OCCURS IN AXILLAE, UNDER BREASTS & GROIN/ANAL
AREA
• CHRONIC INFLAMMATORY CONDITION, MORE COMMON IN PATIENTS
WHO ALSO EXPERIENCE ACNE
• CAN GET SECONDARILY INFECTED WITH BACTERIA (OFTEN STAPH)
HIDRADENITIS SUPPURATIVA
PATIENT WITH A RASH
• 42 Y.O. MALE CALLS YOUR OFFICE FOR HIVES AND AN ITCHY RASH
THAT OCCURRED 10 MINUTES AFTER BEING STUNG BY A BEE. HE HAS
HIS SON’S EPI-PEN AT HOME.
• WHAT ELSE SHOULD YOU ASK TO DETERMINE TREATMENT?
QUESTIONS
• CLINICAL MANIFESTATIONS OF ANAPHYLAXIS
• SKIN
• FLUSHING, PRURITIS, URTICARIA, ANGIOEDEMA (UP TO 90% WITH
URTICARIA/ANGIOEDEMA)
• UPPER RESPIRATORY
• CONGESTION, RHINORRHEA
• LOWER RESPIRATORY
• BRONCHOSPASM, THROAT OR CHEST TIGHTNESS, HOARSENESS, WHEEZING,
SOB, COUGH (UP TO 60% WITH LARYNGEAL EDEMA)
QUESTIONS
• CLINICAL MANIFESTATIONS OF ANAPHYLAXIS
• GI
• ORAL PRURITIS, CRAMPS, NAUSEA, VOMITING, DIARRHEA
• CV
• TACHYCARDIA, BRADYCARDIA, HYPOTENSION/SHOCK, ARRHYTHMIAS,
ISCHEMIA, CHEST PAIN
MYTHS: ANAPHYLAXIS ALWAYS PRESENTS
WITH CUTANEOUS MANIFESTATIONS
• REALITY
• APPROXIMATELY 10-20% OF ANAPHYLAXIS WILL NOT PRESENT WITH HIVES
OR OTHER CUTANEOUS MANIFESTATIONS
• 80% OF FOOD INDUCED, FATAL ANAPHYLAXIS CASES WERE NOT
ASSOCIATED WITH CUTANEOUS SIGNS OR SYMPTOMS (WEBB, ET AL. 2004)
MYTH: THE CAUSE OF ANAPHYLAXIS IS
ALWAYS OBVIOUS
• REALITY
• IDIOPATHIC ANAPHYLAXIS IS COMMON
• TRIGGERS MAY BE HIDDEN
• FOODS
• LATEX
• PATIENTS MAY NOT RECALL DETAILS OF EXPOSURE
SO WHAT SHOULD THIS PATIENT DO?
• GO TO THE ED
• USE THE EPI-PEN AND GO TO THE ED
• USE BENDARYL AND GO TO THE ED
• USE THE BENADRYL AND EPI-PEN AND GO TO THE ED OR CLINIC
EMERGENCY TREATMENT
• IMMEDIATE TREATMENT WITH EPINEPHRINE
• NO CONTRAINDICATIONS IN ANAPHYLAXIS
• FAILURE OR DELAY ASSOCIATED WITH FATALITIES
• IM MAY PRODUCE MORE RAPID, HIGHER PEAK THAN SC
• NEED TO HAVE AVAILABLE AT ALL TIMES; EPI-PEN
• ANTIHISTAMINE (ORAL OR PARENTERAL, IF ORAL USE LIQUID OR
CHEWABLE)
• CALL 911; PROCEED TO ED
OTHER CONSIDERATIONS
• ALLERGY TESTING AND POSSIBLE IMMUNOTHERAPY
• DEVELOP EMERGENCY PLAN
• EPI-PEN AT ALL TIMES
• USE OF ANTIHISTAMINE AND WHEN TO SEEK CARE
CASE: PATIENT WITH A RASH
• A 64 YEAR OLD FEMALE PRESENTS WITH CC: PAINFUL RASH X 1 DAY
HISTORY
• BURNING SENSATION TO LEFT ANTERIOR ABDOMEN AND CHEST X 2
DAYS, THEN ONSET OF RASH. RASH ONLY ON CHEST AND ABDOMEN.
• ROS: DENIES FEVER. C/O HEADACHE. NO OTHER SYMPTOMS
• MEDICAL HISTORY: HYPERTENSION, TYPE 2 DIABETES
• MEDICATIONS: METFORMIN, LISINOPRIL
• ALLERGIES: NONE
PE: RASH
WHAT’S THE DIAGNOSIS?
DIAGNOSIS
• HERPES ZOSTER (SHINGLES)
WHAT’S THE TREATMENT?
TREATMENT
• ACYCLOVIR (AN DERIVATIVES): 7-10 DAYS FOR UNCOMPLICATED
CASES
• USUALLY STARTED WITHIN 48-72 HOURS OF RASH; THOUGH PT. BENEFIT
IF STARTED LATER IN COURSE
• DECREASE SEVERITY AND LENGTH OF ILLNESS; MAY PREVENT PHN
• CORTICOSTEROIDS
• PAIN CONTROL
SYMPTOMATIC TREATMENT
WHO’S AT RISK?
• VZV-SPECIFIC IMMUNITY AND CELL-MEDIATED IMMUNITY, WHICH GENERALLY DECLINES
WITH AGE
• IMMUNOSUPPRESSION (EG, BY HIV INFECTION OR AIDS)
• IMMUNOSUPPRESSIVE THERAPY[
• PRIMARY VZV INFECTION IN UTERO OR IN EARLY INFANCY, WHEN THE NORMAL
IMMUNE RESPONSE IS DECREASED
• ANTI−TUMOR NECROSIS FACTOR (TNF)-Α AGENTS (MAY POSE AN INCREASED RISK)
• IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME (IRIS)
• ACUTE LYMPHOCYTIC LEUKMIA AND OTHER MALIGNANCIES
EDUCATION
• HOW IS SHINGLES PREVENTED?
• IS IT “CONTAGIOUS”?
• WHAT OTHER TREATMENTS CAN BE ADDED?
ANOTHER RASH
• 22 YEAR OLD WITH PRURITIS RASH ON THE HANDS AND SPREADING
TO THE WRIST X 3 DAYS
• NO RECENT ILLNESS
• DENIES OTHER SYMPTOMS
• HEALTHY ADULT
RASH
SCABIES
• WHAT’S THE CLASSIC PRESENTATION?
• HOW IS IT CONTRACTED?
• HOW IS IT TREATED?
REFERENCES
• LUI, C., BAYER, A., COSGROVE, R. DAUM, S.K., FRIDKIN, R., GORWITZ, S.. ET AL.
(2011). CLINICAL PRACTICE GUIDELINES BY THE INFECTIOUS DISEASES
SOCIETY OF AMERICA FOR THE TREATMENT OF METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS INFECTIONS IN ADULTS AND CHILDREN.
• WEBB, L., GREENE, E., & LIEBERMAN, P.L. (2004). ANAPHYLAXIS: A REVIEW OF
593 CASES. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY, 113,
S240.