1
Eczema (Atopic Dermatitis) (1)
? Eczema is associated with asthma and al ergic
rhinitis
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? Erythema, crusts, fissures, pruritis, excoriations,lichenification
? Chronic pruritic skin condition
? Infants: Blisters, crusts, exfoliation (face, scalp,
extremities),1st few months. Resolves by age 2
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? Adults: Dryness and thickening in antecubital andpopliteal fossae, neck
? Positive family history, worse in winter (dry
weather)
2
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Eczema (Atopic Dermatitis) (2)
? Treatment: corticosteroids, antipruritics
? Complications
?2? bacterial infection (treat with antibiotics)
?Eczema herpeticum: Widespread HSV infection
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in patients with underlying atopic dermatitis3
Eczema (Atopic Dermatitis)
4
Med-Chal enger ? EM
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Eczema (Atopic Dermatitis)
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Eczema (Atopic Dermatitis)
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Eczema (Atopic Dermatitis)
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Med-Chal enger ? EM
Allergic Contact Dermatitis
? Delayed type hypersensitivity
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? Poison ivy, poison oak, poison sumac (linearextension)
? Contact with metal jewelry (nickel)
? Hair dyes, detergents
? Erythema, pruritus, vesicles, bul ae
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? Blister fluid contains no antigen? Corticosteroids for severe cases
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Contact Dermatitis
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Med-Chal enger ? EMContact Dermatitis
Logical Imag10
es Inc.
Contact Dermatitis
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Contact Dermatitis
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Poison Ivy
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Exfoliative Dermatitis (1)
? Generalized dermatitis, diffuse, scaly, warm,
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erythematous, non-tender, pruritic? Leads to exfoliation
? Most are secondary to underlying disease
? Involves most or al of skin
? Flares of pre-existing skin disease (psoriasis,
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atopic dermatitis etc.)Differential: SSSS, EM, TEN ,TSS
14
Exfoliative Dermatitis (2)
? Response to drugs, chemicals, systemic
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disease or malignancy (lymphoma, leukemia)? May be acute, subacute or chronic
? Typical y males over 40
? Complications are 2? to disruption of epidermis
?Hypothermia, volume loss, electrolyte
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abnormalities, 2? skin infection? Important to diagnose underlying cause
? Admit, IV, steroids for severe cases
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Exfoliative Dermatitis
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16Psoriasis
? Chronic papulosquamous eruption
?Due to more rapid cel cycle
? Erythematous plaques with white (silver)
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scales? Extensor surfaces of elbows, knees, scalp,
palms, soles
? Pitting of the nails
? May be accompanied by psoriatic arthritis
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? Treatment: steroids, tar, UV light, methotrexate17
Psoriasis
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Psoriasis
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Psoriasis
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Logical Images Inc.Seborrheic Dermatitis (Dandruff)
? White, yel ow, waxy scales with erythema
? Localized to hairy skin areas
? Scalp, eyebrow, ear, axil a, groin (wherever
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there are sebaceous glands)? Malassezia furfur (a fungus) is associated
? Not contagious
? Frequent recurrences, worse in cold weather
? May be severe or generalized in HIV positive
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patients? Treatment: Rotating antidandruff shampoos,
ketoconazole shampoo or cream; steroids are
discouraged
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Seborrheic Dermatitis
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Seborrheic Dermatitis
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Logical Images Inc.Pityriasis Rosea
? Children, young adults, spring and fal
? Etiology unknown
? No epidemics, not contagious
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? Rash evolves over weeks?Herald patch: Single salmon-colored lesion with
raised boarder on trunk, 1?5 cm
?1-2 weeks after herald patch: Widespread
eruption, pink maculopapular oval patches that
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fol ow the ribs ("Christmas tree" pattern)? Rule out syphilis (if clinical y indicated), drug
reaction
? Treatment: Symptomatic, antihistamines
? Resolution in 2-10 weeks
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24Pityriasis Rosea
Christmas
Tree
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Pattern25
Pityriasis Rosea
Herald Patch
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Med-Chal enger ? EMPityriasis Rosea
Herald Patch
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Logical Images Inc.Petechiae / Purpura
? Deposits of blood under skin
? Non-blanching
? Petechiae <3 mm, purpura >3 mm
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? Non-palpable: Platelet disorder,thrombocytopenia
? Palpable purpura = Vasculitis
? Treatment: Antibiotics, steroids,
plasmapheresis (depends on etiology)
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28Petechiae / Purpura
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Petechiae / Purpura30
Urticaria
? Diffuse pruritus, wheals, hives
(superficial dermis)
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? Etiology is unknown most of time? IgE mast cel s histamine release
? Usual y self-limited
? Treatment: Antihistamines, steroids,
antipruritics, H2 blockers, epinephrine
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31Urticaria
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Urticaria
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Angioedema (1)
? Bradykinin-mediated
? Vasodilation
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? Vascular permeability? Edema of the deeper dermis
? Common cause: ACE inhibitors
?ACE inhibitors decrease metabolism of
bradykinins
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?Can occur early or late? 2/3 occur in hours
? 1/3 in months to years
34
Angioedema (2)
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? Familial - associated with C1 esterase inhibitordeficiency
? C esterase inhibitor inhibits complement
1
cascade
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?Deficiency leads to increased bradykinin? Edema of face, extremities, bowel wal
? Responds to fresh frozen plasma and C1
esterase inhibitor concentrate
? Autosomal dominant (positive family history)
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35Angioedema
36
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Erysipelas
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? Infants, toddlers, elderly? Usual y Group A Strep, occasional y Staph
? Superficial cel ulitis, lymphangitis
? Localized (face, legs, ear)
? Butterfly facial rash (warm and tender)
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? Raised, well demarcated border? Treatment: PCN, dicloxacil in, erythromycin
37
Erysipelas
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Logical Images Inc.Erythema Nodosum (EN)
? Painful, non-ulcerative, violaceous nodules
(localized vasculitis) on anterior tibia, arms,
trunk
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?Looks like erythema, feels like nodes? EN is often a marker for systemic disease
?Drug reaction (oral contraceptives, sulfa, PCN)
?Systemic infection (TB, fungal)
?Sarcoid
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?Inflammatory bowel disease (ulcerative colitis)?Malignancy (leukemia, lymphoma)
? Most common in women 30-50
? Resolves in 3-6 weeks
? Treatment is directed at underlying disease 39
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Erythema Nodosum
6
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Erythema Nodosum41
Drug Eruption
? Consider in any acute, symmetrical eruption
? Common: PCN, cephalosporins, sulfa
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? Usual y disappears within 1-2 weeks? Immediate hypersensitivity: IgE (urticaria)
? Delayed hypersensitivity: IgM (serum sickness)
? Urticaria, morbil iform rash (discreet red-brown
papules coalesce to erythema), erythema
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multiforme? Treatment: Discontinue drug, antihistamines,
steroids
? Complications: Stevens-Johnson syndrome
(mucosal and cutaneous), Severe bul ous
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(form can be fatal)42
Erythema Multiforme
? Minor (erythema multiforme) EM major
(Stevens-Johnson) EM maximum (TEN)
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? Hypersensitivity reaction?Infection (Mycoplasma, Herpes), malignancy,
drugs
?Sulfa, oral hypoglycemics, anticonvulsants, PCN
(memory aid: "SOAP")
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? Palms, soles, extensor surfaces? "Bull's eye" or "target" lesions
? Treatment: Remove offending agents;
symptomatic for minor forms; major forms may
need resuscitation, ICU admission
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43Erythema Multiforme
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Erythema Multiforme
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Stevens-Johnson Syndrome
? Severe bul ous form of EM, 10-30% of BSA,
mucosal involvement, can be fatal
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? Bul ous cutaneous lesions, mucositis,stomatitis, conjunctivitis, crusted nares
? Children, adolescents, males
? Serious, potential y fatal form of E. multiforme
?Hypersensitivity reaction
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?Severe reaction to medication: SulfonamidesPCN, barbiturates, phenytoin, tetracycline,
thiazides
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Stevens - Johnson Syndrome
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Stevens - Johnson Syndrome
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Toxic Epidermal Necrolysis (TEN) 1
? Erythema multiforme, Stevens-Johnson
syndrome and TEN
?Probably variants of the same disease process.
The difference is in severity and body surface
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area affected?TEN affects >30% of BSA
? Exposure to drugs, chemical agents, infections
?Sulfa, PCN, barbiturates, phenytoin, al opurinol,
NSAIDs
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?Mycoplasma, HSV? Toxic patient, large bul ae, mucous membranes,
widespread systemic manifestations
49
Toxic Epidermal Necrolysis (TEN) 2
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? Separation of dermal-epidermal junction? Nikolsky's sign: Skin peels off with light
pressure
? Older age group has high mortality
? Increased mortality from dehydration and 2?
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infection? Primary causes of death: Sepsis, pneumonia
? Treatment: Admit to ICU
50
Toxic Epidermal Necrolysis
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Toxic Epidermal Necrolysis
1
52
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Logical Images Inc.Toxic Epidermal Necrolysis
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Staphylococcal Scalded Skin Syndrome
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? Usual y children <2 years old? Staph aureus exotoxin
? Fever, scarlatiniform rash fol owed by
exfoliation
? Nikolsky's sign: Skin peels off with light
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pressure? Antibiotics (vancomycin) indicated, but do not
alter cutaneous disease
? More favorable prognosis than TEN
? Steroids are contraindicated
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54Staphylococcal Scalded Skin Syndrome
55
Med-Chal enger ? EM
Staphylococcal Scalded Skin Syndrome
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Pemphigus Vulgaris
? Painful intradermal bul ae, 40-60 years old,
possible autoimmune etiology
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? Associated with penicil amine, captopril,phenobarbital
? Bul ae appear on normal skin, often start in mouth
? Blisters are fragile, break easily, leave red or
crusted erosions
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? Mucus membranes are frequently involved? Smal flaccid bul ae erosions, ulcerations
? Nikolsky sign positive (like TEN)
? Can be lethal: Mortality due to secondary
infection, dehydration
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? Treatment: Steroids, admission, biopsy57
Pemphigus Vulgaris
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Pemphigus Vulgaris
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Med-Chal enger ? EM
Bullous Pemphigoid
? Chronic benign bul ous eruption. Autoimmune
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disease? Risk factors: Age > 60, female, malignancy,
furosemide (Lasix)
? Begins with urticarial lesions, then tense blisters
up to 10 cm
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? Large bul ae (2-5 cm) arise from erythematous skin? Mucus membranes infrequently involved
? Nikolsky sign negative
? IgE deposited on basement membrane
? Course is usual y benign. Mortality much less than
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in pemphigus60
Bullous Pemphigoid
61
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Pemphigus Vulgaris
Bullous Pemphigoid
? Fragile, smal er blisters
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? Tense, larger blisters? Painful
? Chronic
? Can be lethal
? Benign
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? Positive Nikolsky's? Negative Nikolsky's
62
Basal Cell Carcinoma
? Most common skin malignancy
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? Pearly, rolled border with central ulceration? Not a metastasizing tumor
? Slow growing, usual y head and neck
? Seen only where hair fol icles exist
? Cure rate 100% if found early
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63Basal Cell Carcinoma
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Basal Cell Carcinoma
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Logical Images Inc.Malignant Melanoma
? Increasing incidence
? Ages 30-50
? Risk factors: Adulthood, dysplastic nevi, family
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history of melanoma, fair skin, UV exposure,congenital nevi
? Account for majority of deaths due to skin
cancer
? Sun exposed areas (head, neck, trunk)
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? The greater the depth, the worse the prognosis? Metastases are common
66
Malignant Melanoma
67
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Med-Chal enger ? EMMalignant Melanoma
68
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Squamous Cell Carcinoma
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? Second most common cutaneous malignancy? Common in elderly males, fair skin, sun
exposure
? Face, lips, ears, tongue, hands
? Rapid growth, central ulcer, raised and
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indurated border? Metastases occur early
? Treatment: Excisional surgery, radiation
69
Squamous Cell Carcinoma
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70Squamous Cell Carcinoma
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Tinea (Dermatophytosis) (1)
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? Tinea capitis (scalp) and tinea barbae (beard)?Bald, broken hair
?Scaly patch
?Edematous nodules and pustules (kerion)
? Tinea corporis (ringworm)
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?Non-hairy parts of the body, outwardspreading, annular lesion, clear center
? Tinea pedis (athlete's foot)
? Tinea cruris (jock itch)
?Groin and inner thigh (sharp demarcation)
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?Scrotum not involved72
Tinea (Dermatophytosis) (2)
? Causes: Trichophyton, Microsporum,
Epidermophyton
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? Treatment: Antifungal (topical or oral)73
Tinea
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CapitisCorporus
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Tinea Cruris
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75Tinea Versicolor
? Hypopigmented or
hyperpigmented
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circular, scaly patches? Poor hygiene, moisture
? Malassezia furfur
? Treatment: Selenium
shampoo,
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ketoconazole shampooor cream
76
Spirochetes
77
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Leptospirosis
? Pathogenic spirochete
? Reservoirs: Rats, cattle, pigs, dogs
? Skin contact with urine of infected animal
? Contaminated water
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? Hepatitis, nephritis, meningitis, coagulopathy? Weil's disease (severe form): Jaundice,
subconjunctival hemorrhage, hepatitis, DIC
? Risk of death from hepatorenal failure
? Diagnosis by serology
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? Treatment: Pen G, tetracycline, doxycycline 78Lyme Disease (1)
? Borrelia burgdorferi (spirochete)
? Transmitted by bites of Ixodes ticks
? Tick reservoirs: Rodents, rabbits, deer
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? Most do not recal tick bite? Fever, myalgias, arthralgias, headache
? 3 stages
? Localized (rash)
? Disseminated (neurologic and cardiac)
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? Persistent (arthritis)79
Lyme Disease (2)
? Erythema migrans: Annular, expanding
erythematous lesion with central clearing
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(spares palms, soles)? Neuro: CN VII palsy, meningitis, peripheral
neuropathy
? Cardiac: Myocarditis, pericarditis, heart block
? Diagnosis: ELISA (screening); Western blot
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? Treatment: Doxycycline, amoxicil in,cefuroxime; macrolides if others not tolerated
? Probable risk = Test
? Probable disease = Treat
80
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Lyme Disease
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Lyme Disease
82
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Logical Images Inc.Lyme Disease
83
Meningococcemia (1)
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? N. meningitidis (encapsulated Gramnegative diplococcus)
? Broad spectrum of disease
?Bacteremia, sepsis, meningitis
? Fever, myalgias, headache, rash
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? 1-2 mm petechiae purpura? Poor prognosis if petechiae, hypotension,
T> 40 ?C, decreased platelets, no
meningismus or leukocytosis
84
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Meningococcemia (2)
? Prophylaxis: Close contacts, nursing home,
dormitory, family
?Prophylaxis is not indicated for brief hospital
encounter (ER patient, no close contact)
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? Rifampin, Cipro for prophylaxis? Diagnosis: CSF and blood serology, cultures
? Treatment: PCN, chloramphenicol, isolation
Waterhouse-Friderichsen syndrome:
shock, petechiae, adrenal infarction
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85Meningococcemia
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Meningococcemia
87
Necrotizing Soft Tissue Infections(1)
? Virulent, toxin-producing bacteria
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? Often seen with IVDU? Widespread fascial and muscle necrosis,
sparing of skin
? Crepitant anaerobic cel ulitis (necrotic soft
tissues, subcutaneous gas)
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? Myonecrosis (clostridial, non-clostridial)? Necrotizing fasciitis (rapid dissection and
necrosis in superficial and deep fascial
planes)
88
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Necrotizing Soft Tissue Infections(2)
? Necrotizing fasciitis
?"Flesh-eating" bacteria
?Strep, clostridia, polymicrobial
?"Pain out of proportion" is hal mark
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?Surgical emergency?Pen G + imipenem, or amp + gent + clinda
?Fournier's gangrene: Necrotizing fasciitis
involving scrotum, vulvar or perianal skin
89
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Necrotizing Soft Tissue Infections
Subcutaneous Air
90
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Necrotizing Soft Tissue Infections
Necrotizing Soft Tissue Infections
Subcutaneous Air
91
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Methicillin Resistant
Staph aureus (MRSA) (1)
? Hospital acquired MRSA
?Hospitalized, dialysis, IVDU, nursing home
? Community acquired MRSA
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?Skin and soft tissue infections?High prevalence in many areas
?Resistant to beta-lactam antibiotics
?Milder infections: Trimethoprim/
sulfamethoxazole or clindamycin
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?Serious infections: Vancomycin or linezolid92
Methicillin Resistant
Staph aureus (MRSA) (2)
93
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Toxic Shock Syndrome
? Staph aureus exotoxin
? Prolonged tampon use, packed surgical
wounds, nasal packing
? Menstruating females, postpartum, also in
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males? Fever, hypotension
? Rash: Diffuse, erythematous, nonpruritic,
macular
? Involvement of at least three systems
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?Renal, hepatic, hematologic, GI,musculoskeletal, mucosal, CNS
? Treatment: Fluids, remove source, antibiotics
? Group A Strep variant (higher mortality)
94
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Tick-Borne Infections
95
Rocky Mountain Spotted Fever (RMSF)(1)
? Rickettsia rickettsii (obligate intracel ular
bacterium)
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? Bite from infected tick? Most cases seen in April-September (tick
season)
? Commonly seen in children <15
? Endemic in Southeastern US
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? Fever, headache, myalgias? Smal pink macules petechiae, purpura
(from a vasculitis) / (wrists, ankles)
96
Rocky Mountain Spotted Fever (RMSF)(2)
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? Rash begins on extremities, wrists, ankles,palms and soles
? Spreads up trunk, spares face
? Lab: WBC count normal, left shift, mild anemia,
moderate thrombocytopenia, hyponatremia
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? Diagnosis: Clinical (don't wait for serology tests)? Treatment: Doxycycline preferred, chloramphenicol
? Complications (due to vasculitis)
?DIC
?Loss of limbs
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?CNS?Lungs
?Kidneys
97
Rocky Mountain Spotted Fever
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Rocky Mountain Spotted Fever
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Ehrlichiosis
? Clinical presentation similar to rocky mountain
spotted fever
? Transmission through tick bite
? Two types
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?HME: human monocytic?HGE: human granulocytic
? Fever, headache, myalgias
? Maculopapular rash
? Leukopenia, thrombocytopenia, hyponatremia,
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anemia, LFTs? Diagnosis: Clinical suspicion
? Treatment: Doxycycline, tetracycline,
chloramphenicol
? Complications: DIC, renal failure, coma, death 100
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Babesiosis
? Tick-borne hemolytic disease, blood
transfusions
? Intra-erythrocyte protozoan parasite
? Endemic to northeastern USA
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? Fever, chil s, fatigue, malaise? Hepatosplenomegaly, jaundice
? Peripheral blood smear -- parasites in RBCs
? Usual y mild unless asplenic, elderly, or
immunosuppressed
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? Treatment: Quinine plus clindamycin;Atovaquone plus azithromycin
101
Viral Infection
102
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Cytomegalovirus (CMV)
? A member of the herpes virus group (dormant
until reactivated)
? The most common of the TORCHES infections
? Congenital: Chorioretinitis, jaundice,
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hepatosplenomegaly, deafness, rash? Acquired: Asymptomatic or mono-like il ness
? Immunocompromised: CMV retinitis, nephritis,
pneumonitis, colitis. Carries high mortality
? Diagnosis: Atypical lymphocytosis, ELISA
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? Treatment: IV ganciclovir or foscarnetTORCHES
Toxoplasmosis, Rubella, CMV, Herpes, Epstein-Barr, Syphilis
Organisms associated with congenital transmission
103
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Congenital CMV
104
Cytomegalovirus (CMV)
105
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Herpes Simplex
? HSV-1: Stomatitis, fever, decreased fluid intake,
oral lesions, corneal ulcers (steroids are
contraindicated)
? Herpetic whitlow: Vesicles grouped on digits,
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non-surgical treatment, often misdiagnosed? HSV-2: Painful vesicles of genitalia and anus
? Diagnosis: Viral culture, PCR
? Complications: Congenital transmission
(TORCHES), encephalitis
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? Treatment: Acyclovir and analogs, vidarabine106
Herpes Simplex
107
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Herpetic Whitlow
108
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Herpes Simplex ? Genital
109
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Logical Images Inc.Herpes Zoster (Shingles)
? Varicel a-zoster virus reactivation
? Painful vesicles in dermatome distribution
? Cranial nerve involvement
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?HZ ophthalmicus: Opthalmic branch of CN V,lesion seen on tip of nose (Hutchinson's sign),
vision- threatening
?Ramsay Hunt: CN VII, zoster presenting with
facial nerve palsy, ear pain
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? Complications: Pneumonia, meningitis, post-herpetic neuralgia, 2? infection, dissemination
? Treatment: Acyclovir and analogs, prednisone
110
Herpes Zoster
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Herpes Zoster
112
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Herpes Zoster
113
Med-Chal enger ? EM
Acquired Immune Deficiency (1)
? HIV types 1, 2 (RNA retroviruses)
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? Virus multiplication in CD4 lymphocytes? CDC classification:
?Group l: Acute mono-like infection
seroconversion
?Group II: Asymptomatic infection
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?Group III: Lymphadenopathy >3 months?Group IV: AIDS (CD4 <200, opportunistic
infections)
114
Acquired Immune Deficiency (2)
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? Pneumocystis (PCP) is the most frequentinfection
?CXR: bilateral infiltrates, hypoxemia
?Treatment: TMP/SMX, steroids
? Cryptococcal meningitis
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?Most common CNS fungal infection?Diagnosis: CSF (India ink, cryptococcal antigen)
?Treatment: amphotericin B
? Toxoplasmosis
?Most common cause of encephalitis
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?Diagnosis: CT (ring-enhancing lesions)?Treatment: pyrimethamine, sulfadiazine
? Oral candida is most common GI tract infection
115
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Oral Candidiasis116
Kaposi's Sarcoma
? Second most common AIDS manifestation
? Seen in men who have sex with men (MSM)
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? Not a cause of significant morbidity or mortality? Purple, painless, non-pruritic areas, flush with
skin or raised strawberry-like plaques
? Persist, enlarge, coalesce, may bleed
? Extracutaneous involvement: GI tract, liver,
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spleen, lungs, CNS117
Kaposi's Sarcoma
118
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Kaposi's Sarcoma
119
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Molluscum Contagiosum
? Viral infection of skin (poxvirus)
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? 2-5 mm umbilicated, pink, dome-shapedpapules
? Autoinoculation: Common locations are face,
trunk, extremities (children), groin and genitalia
(adults). Usual y self-limited
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? Transmission: Close personal contact,swimming pools. Sexual transmission is
common in adults
? HIV/AIDS: Not uncommon, lesions can be
extensive and atypical
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120Molluscum Contagiosum
121
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Infectious Mononucleosis
? Epstein-Barr virus (EBV)
? Common in adolescents. Usual y
asymptomatic in infants and children
? Fever, exudative pharyngitis, splenomegaly,
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lymphadenopathy, atypical lymphocytosis? Complications: Splenic rupture,
thrombocytopenia
? Diagnosis: Monospot, serology
? Amoxicillin almost always causes a
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maculopapular rash (may be diagnostic)? Treatment: Rest, supportive, no contact sports
122
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Mononucleosis80
123
Common Pediatric Rashes
124
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TORCHES
? A col ection of congenital infections that
can cause severe fetal abnormalities that
are associated with a variety of dermatologic
manifestations
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?T = Toxoplamosis?oR = Rubel a
?C = Cytomegalovirus (most common)
?H = Herpes simplex / HIV / Hepatitis
?E = Epstein-Barr
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?S = Syphilis125
Erythema Infectiosum (Fifth Disease)
? Human Parvovirus B19
? Fever, myalgias, diarrhea, URI symptoms, flu
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symptoms? Rash: Abrupt onset, bright red cheeks
(slapped cheeks), tiny papules on
erythematous base, eyelids and chin spared
? "Lace-like" erythematous rash on limbs, trunk
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? Complications: Arthritis, aplastic crisis(especial y in sicklers)
? Can cause fetal anemia if acquired during
pregnancy
? Treatment: NSAIDs
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126Erythema Infectiosum
127
Hand-Foot-Mouth Disease
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? Coxsackie virus (enterovirus)? Occurs in outbreak
? Fecal-oral transmission
? Fever, sore throat, malaise, URI
? Oral lesions: Painful vesicles on anterior mouth
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(buccal mucosa, tongue, soft palate, gingiva)? Skin lesions: Red papules (change to gray
vesicles) on palms, soles, buttocks
? Vesicles on hands, feet, soles
? Avoid viscous lidocaine in young children
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because of risk of seizures128
Hand Foot and Mouth Disease
129
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Hand Foot and Mouth Disease
130
Hand Foot and Mouth Disease
131
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Herpangina
? Coxsackie virus
? Fecal-oral transmission, preschool age,
spreads to siblings
? Fever, dysphagia, drooling, vomiting,
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headache? Ulcerative lesions (vesicles rupture, leaving
painful ulcers on posterior pharynx, soft palate,
uvula)
? Complications are rare
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? Resolves in 1 weekAnterior mouth spared
132
Herpangina
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133Henoch-Sch?nlein Purpura
? Most common acute vasculitis affecting children
? Preceding Strep or GI infection (Salmonel a,
Shigel a)
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? Ages 2-10, abdominal pain, GI bleeding,hematuria
? Palpable purpura (legs, buttocks)
? Thrombocytopenia is absent
? Complications: Arthritis, glomerulonephritis,
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hematuria, GI bleeding, intussusception? Renal consult
? Usual y resolves spontaneously
134
Henoch-Sch?nlein Purpura
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135Logical Images Inc.
Henoch-Sch?nlein Purpura
136
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Henoch-Sch?nlein Purpura
137
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Kawasaki's Disease (1)
? Mucocutaneous lymph node syndrome
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? About 2,000 cases/yr in the U.S.? Acute, febrile, exanthematous disease of
children (age 2-5, males, Asian)
? Self-limited vasculitis with predilection for
coronary arteries
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? Cause unknown? Possibly an immune response to bacterial
infection, since it occurs in outbreaks
138
Kawasaki's Disease (2)
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? Major criteria: Fever >5 days PLUS 4 of thefollowing
?Conjunctival injection (bilateral)
?Strawberry tongue, fissures, lips cracked
?Desquamation or swel ing of fingers and toes
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?Erythematous rash (starts on palms and soles)?Enlarged (15mm or greater) cervical lymph
nodes
? WBC, ESR, platelets
? Coronary artery aneurysms
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? Treatment: Aspirin, IV immunoglobulin139
Kawasaki's Disease
140
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Med-Chal enger ? EMKawasaki's Disease
141
Impetigo
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? Staph. aureus, Strep. pyogenes? Superficial epidermis, no fever, highly contagious
? Preschool, young adults, poor hygiene
? Red, moist vesicles
? Painless, honey-crusted lesions
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? Rarely causes glomerulonephritis (antibiotics donot prevent this)
? Treatment: Dicloxacil in, cephalosporin,
erythromycin, mupirocin ointment
? Bul ous impetigo suggests Staph infection
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142Impetigo
143
Med-Chal enger ? EM
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Bullous Impetigo
144
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Impetigo
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145
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Impetigo
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146Logical Images Inc.
Impetigo
147
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Logical Images Inc.Rubella (German Measles)
? Acute viral il ness (fever, sore throat, headache)
? "Three day measles"
? Rash (pink macules spread from head to feet)
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Prominent lymphadenopathy:posterior auricular, cervical, occipital
? Complications
?Arthritis (immune complex)
?Encephalitis
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?1st trimester pregnancy (congenital defects)148
Rubella
149
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Rubella
150
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Rubeola (Measles)
? Fever, cough, conjunctivitis, coryza (3 "C"s)
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? Koplik spots: Buccal mucosa (before rash),non-tender, tiny white spots ("grains of salt")
? Maculopapular, red-brown "morbil iform" rash
spreads from head to feet
? Complications: Encephalitis, pneumonia,
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otitis media, conjunctivitis151
Measles
152
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Measles
153
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Measles
154
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Logical Images Inc.Koplik's Spots
155
Med-Chal enger ? EM
Roseola Infantum
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? Exanthem subitum? Human herpes viruses (HHV) 6 and 7
? Common at ages 6-18 months
? High fever (3-4 days), then rash with
defervescence
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? Febrile seizures are common? Pink macules and papules on trunk
? May spread to neck, face, extremities
156
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Roseola157
Pediculosis (Lice)
? Head lice
?Scalp and neck (erythema, scaling)
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?Nits (eggs) attached to the hair shaft? Body lice
?Linear excoriations, nits in seams of clothing
? Pubic lice (crabs)
?Sexual y transmitted
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?Intense pruritus, papular urticaria on thighs andabdomen
? Treatment: Extensive cleaning of clothing and
bedding, pediculicide creams and shampoos
(pyrethrin, permethrin)
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158Pediculosis (Lice)
159
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Scabies
? Severe pruritus (due to hypersensitivity reaction
to scabies mite)
? Web spaces, elbow, axil a, groin (favors thin
skin)
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? Red papules, vesicles, crusts, linear burrows? Treatment: Permethrin cream, ivermectin; may
consider using lindane lotion (>2 yrs)
? "Norwegian scabies" (severe disease) seen in
immunocompromised
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160Scabies
161
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Scabies
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162Logical Images Inc.
Scabies
163
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Scabies
164
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Scarlet Fever
? Group A beta hemolytic Strep toxin
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? Sore throat, fever, headache, vomiting? Sandpaper rash starts on flexor creases and
moves to trunk and extremities; circumoral
sparing
? "Strawberry" tongue
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? Groin, axil a, antecubital areas (Pastia's lines)? Skin peeling (palms and soles)
? Diagnosis: Throat swab, increasing ASO titer
? Treatment: Pen G
165
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Scarlet Fever
166
Med-Chal enger ? EM
Scarlet Fever
Logical Ima 167
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ges Inc.Scarlet Fever
168
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Varicella (Chicken Pox)
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? Varicel a zoster virus? Fever, malaise, URI
? Macules, papules vesicles ("dewdrop on a
rose petal") that come in crops crusts
? Complications (mostly adults): Pneumonia,
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encephalitis, otitis media, 2? infection? Treatment: Acyclovir or analogues
? Avoid salicylates (Reye's syndrome)
? Prevention: Immune globulin if
immunocompromised or pregnant, vaccine in
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kids and non-immune adults169
Chicken Pox
170
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Chicken Pox
171
Varicella
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172Logical Images Inc.
Varicella
173
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Varicella
174
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Six Childhood Infectious
Diseases Associated with Rashes
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InfectionCharacteristics
Measles
Rash begins at head and goes down
(Rubeola)
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Cough, coryza, conjunctivitis (the 3 C's)Chicken pox
Macules to papules to vesicles to crusted lesions
(Varicela)
Varying stages simultaneously
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German measlesRash begins at head and goes down
(Rubel a)
Three day measles
Prominent lymphadenopathy
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Scarlet feverStrep throat with sand paper truncal rash
Erythema infectosum Slapped cheeks
(Fifth Disease)
Roseola Infantum
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Fever, then truncal rash when fever is gone(Sixth Disease)
175
Occupational Exposures (1)
Hepatitis B
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? HB Surface antigen = Infectious? HB Surface antibody = Protective
? HB e antigen = Highly infectious
? Per the CDC, a needle stick or cut exposure if
not successful y vaccinated = 6-30%
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? Risk is at the high end of the range (25-30%) ifsource is HBeAg-positive
176
Occupational Exposures (2)
Hepatitis B vaccination
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? Very safe vaccine? Three-dose series (0, 1, 6 months)
? Test for seroconversion (desired antibody level
>10 mIU/mL)
? Repeat series if non-responder
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? No boosters if responderHepatitis B Immune Globulin (HBIG)
? Passive immunization (pooled antibodies)
? Effective within 1 week of exposure
177
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Occupational Exposures (3)
? Management of possible hepatitis B
exposure
?Test source for HB surface antigen
?Test exposed patient for HB surface antibody
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? Exposure to HBsAg-positive source? If the healthcare worker is unvaccinated, give HBIG
and start the vaccine series
? If the healthcare worker has protective levels of
antibody (>10 mIU/mL), no treatment is needed
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? Special circumstances (known non-responders,partial y vaccinated) -- look it up!
178
Occupational Exposures (4)
Hepatitis C
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? Percutaneous transmission is common? Sexual transmission is rare
? Per the CDC, after a cut or needle stick
exposure the seroconversion risk about 2%
? Test source for anti-HCV
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? No effective post-exposure prophylaxis? If positive do serial tests of the healthcare
worker for anti-HCV and liver enzymes
179
Occupational Exposures (5)
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HIV exposure? Transmission after percutaneous exposure
0.3%
? Risk of transmission is increased when
?Contaminating device is visibly contaminated
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with blood?A needle is placed directly into a blood vessel
?Injury is deep
?Contamination is with a hol ow bore needle
?Source is likely to have a heavy viral load (as
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occurs in terminal HIV)? Post-exposure prophylaxis recommended for
significant HIV exposures
180
Occupational Exposures (6)
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HIV Post-Exposure Prophylaxis? For HIV-positive exposures
? HIV test source and healthcare worker
? Start medications within 1-2 hours of
exposure
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? Multi-drug protocols are standard? Reverse transcriptase inhibitors (e.g.,
zidovudine, lamivudine) and protease
inhibitors are used
? Side effects often limit treatment
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? PEP is continued for 4 weeks? Consult ID for most cases
181
DERMATOLOGY
QUESTIONS
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Review the picture on the slide and then answer thequestion on the slide that follows.
182
DE 1 183 1
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Which of the following is TRUE
about the above slide?
A.It is usual y fol ows a benign course
B.Mucus membranes are rarely involved
C.Nikolsky sign is negative
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D.The lesions are painlessE.The vesicles a fragile and break easily
DE 1 184 1
DE 2 185 2
Which of the following is TRUE
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about the above slide?A.It is a type of acute hypersensitivity
B.Linear pattern helps make the
diagnosis
C.Steroids are contraindicated
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D.The blister fluid contains antigenE.The rash does not itch
DE 2 186
DE 3 187
Med-Chal enger ? EM 3
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Which of the following is TRUE
about the above slide?
A.Aplastic crisis may be a complication
B.No other symptoms are associated
with this rash
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C.NSAIDs should be avoidedD.The rash starts after the patient
defervesces
E.The chin and eyelids are usual y
involved
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DE 3 188 1DE 4 189 5
Which of the following is TRUE
about the above slide?
A.It does not require antibiotic treatment
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B.It is cause by StaphC.Skin peeling is uncommon
D.The circumoral area is spared
E.The rash is seen on extensor surfaces
DE 4 190 1
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DE 5 191 6
Which of the following is TRUE
about the above slide?
A.Antibiotics are indicated
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B.It is caused by a virusC.It is contagious
D.It is seen more often in children and
young adults
E.It wil resolve within a week
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DE 5 192 1DE 6 193 7
Med-Chal enger ? EM
Which of the following is TRUE
about the above slide?
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A.It is not tenderB.It is not warm
C.It is seen only in the elderly
D.The rash tends to be generalized
E.Treatment is with penicil in or
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doxycyclineDE 6 194 1
DE 7 195 8
Which of the following is TRUE
about the above slide?
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A.It is a marker for systemic diseaseB.It is more common in men
C.It resolves quickly (in a couple of
days)
D.Lesions are most commonly found on
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the anterior forearmsE.The lesions are painless
DE 7 196 1
DE 8 197
19
--- Content provided by FirstRanker.com ---
Which of the following is TRUE
about the above slide?
A.Diagnosis is made by culturing the
offending organism
B.It is acquired by a mosquito bite
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C.It is treated with antiviral agentsD.Patients may have cranial nerve
palsies
E.The rash involves the palms and
soles
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DE 8 198 1DE 9 199 9
Which of the following is TRUE
about the above slide?
A.It is the most serious form in a
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spectrum of diseaseB.Lesions are asymmetric
C.Target lesions are rare
D.The lesions al desquamate
E.The patient may be taking phenytoin
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DE 9 200 1DE 10
201
12
Which of the following is TRUE
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about the above slide?A.Affects less than 25% of the body
surface area
B.ICU admission is recommended
C.Is unrelated to Stevens Johnson
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syndromeD.Nikolsky's sign is negative
E.Rarely associated with exposure to
drugs
DE 10
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2021
DE 11
203
13
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Which of the following is TRUE
about the above slide?
A.Aspirin should be avoided
B.Cerebral artery vasculitis and
aneurysms are a complication
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C.Desquamation is uncommonD.Fever duration of over 5 days is a
diagnostic criterion
E.Seen in patients up to age 18 years
DE 11
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2041
DE 12
205
30
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Which of the following is TRUE
about the above slide?
A.Cough is rare
B.It is one of the "TORCH" infections
C.Koplik's spots may be found in the
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mouthD.Posterior lymphadenopathy is
characteristic
E.The rash typical y lasts three days
DE 12
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2061
DE 13
207
29
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Med-Chal enger ? EMWhich of the following is TRUE
about the above slide?
A.Complications are common in children
B.It may be accompanied by fever and
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malaiseC.Salicylates are indicated
D.There is no vaccine for this infection
E.The lesions al develop
simultaneously
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DE 13208
1
DE 14
209
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Which of the following is TRUE
about the above slide?
A.Blisters can be large and tense
B.It has a high mortality rate
C.Mucus membranes are frequently
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involvedD.Nikolsky sign is positive
E.This rash is usual y an acute process
DE 14
210
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1DE 15
211
26
Which of the following is TRUE
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about the above slide?A.It is caused by a bacteria
B.It is spread by respiratory
transmission
C.Lesions are also seen on the torso
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D.Mouth lesions spare the anteriormouth
E.Sore throat and URI symptoms may
be seen
DE 15
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2121
DE 16
213
20
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Med-Chal enger ? EMWhich of the following is TRUE
about the above slide?
A.It is caused by a virus
B.It is seen most commonly in the winter
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C.It is transmitted by a tick biteD.The rash begins on the trunk and
spreads to the extremities
E.The rash often involved the face
DE 16
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2141
DE 17
215
27
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Which of the following is TRUE
about the above slide?
A.Immunocompromised patients are not
at increased risk of severe disease
B.The axil a and groin tend to be spared
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C.The rash is due to a hypersensitivityreaction
D.The rash is not itchy
E.Treatment is to wash the skin off
DE 17
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2161
DE 18
217
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23Which of the following is TRUE
about the above slide?
A.Does not resolve without intervention
B.GI bleeding is a complication
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C.It is the most common acute vasculitisaffecting adults
D.The rash associated with a viral
infection
E.Thrombocytopenia is common
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DE 18218
1
DE 19
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21924
Which of the following is TRUE
about the above slide?
A.Bul ous lesions suggest a Staph
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infectionB.Fever is common
C.It is a deep skin infection
D.It is not contagious
E.It is painful
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DE 19220
1
DE 20
221
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21Which of the following is TRUE
about the above slide?
A.Antibiotics are indicated
B.Diagnosis is made by wound culture
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C.The causative organism is not oneof the TORCH infections
D.The causative organism may also
cause oral lesions
E.The lesions should be incised and
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drainedDE 20
222
1
Dermatology Answer Key
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1. E11. D
2. B
12. C
3. A
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13. B4. D
14. A
5. D
15. E
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6. E16. C
7. A
17. C
8. D
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18. B9. E
19. A
10. B
20. D
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223Diseases Pictured
Question 1: Pemphigus Vulgaris
Question 2: Contact Dermatitis
Question 3: Fifth Disease (Erythema Infectiosum)
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Question 4: Scarlet FeverQuestion 5: Pityriasis Rosea
Question 6: Erysipelas
Question 7: Erythema Nodosum
Question 8: Lyme Disease
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Question 9: Erythema MultiformeQuestion 10: Toxic Epidermal Necrolysis (TEN)
224
Diseases Pictured
Question 11: Kawasaki's Disease
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Question 12: MeaslesQuestion 13: Varicel a
Question 14: Bul ous Pemphigoid
Question 15: Hand, Foot and Mouth Disease
Question 16: Rocky Mountain Spotted Fever
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Question 17: ScabiesQuestion 18: Henoch-Schonlein Purpura
Question 19: Impetigo
Question 20: Herpetic Whitlow
225
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