Dermatology Exam 1 Lecture 5 (Sandy)

Buboe

Swollen or inflamed lymphnode in groin or axilla

Gumma

Solitary granulomatous lesion with central necrosis.

Psoriasiform

resembling psoriasis

cutaneous rash caused by fever or disease

Exanthema

This is a bacterial illness transmitted via tick bite. It is caused the Rickettsia rickettsii (gram negative bacteria).

Rocky Mountain Spotted Fever (RMSF)

How is RMSF transmitted?

Ticks

Dermacentor variabilis (Dog Tick) is found in the ?

Eastern US

D. andersoni (Wood Tick) that is found in the ?

Southwestern/south central US

Pink macular rash, initially blanching, beginning at the distal extremities (palms/soles). Rash then spreads proximally in 24 hours and becomes hemorrhagic in 4-5 days. What condition is this the characteristic rash of?

RMSF

Is this a description of the Early or Late exanthema that is present in RSMF?

"Hemorrhagic petechiae on palms and soles then rest of body forming purpura, does not blanching, and local edemas present. Next, necrosis in acral extremities occurs."

Later exanthem: 5 to 7 days

Is this a description of the Early or Late exanthema that is present in RSMF?

"2-6mm, pink, blanchable macules on wrists & ankles. Palms and soles may be involved. In 6-18hrs it spreads centrally to arms, thighs, trunk, and face that evolves to deep red papules. "

Early exanthem (2-4 days)

Explain the characteristic rash of RMSF

Pink macular rash, initially blanching, beginning at the distal extremities (palms/soles). Rash then spreads proximally in 24 hours and becomes hemorrhagic in 4-5 days.

Which age group is MC affected by RMSF?

1. Febrile Children

2. Adolescent

3. Men > 60

What symptoms can you see in a pt with RMSF?

1. Fever

2. severe headache,

3. myalgia

3. chills, shaking rigors. Anorexia, N/V, malaise, irritability

Thrombocytopenia and hyponatremia should increase your suspicion for which vector-borne viral condition?

RMSF

What abnormalities can you expect to see on the labs of a patient with RMSF?

Thrombocytopenia

Hyponatremia

The diagnosis is made clinical but needs to be confirmed later by ?

Biopsy of petechial papule or eschar followed by PCR

What is the tx of choice for RMSF?

Doxycycline

Tick borne illness due to spirochete infection where transmission is 24 to 72 hours.

Lyme Disease

Patients generally are not at risk for contracting Lyme disease until the tick has been feeding for ____ hours or more

72 hours

What type of bacteria causes Lyme disease and type of tick transmits it ?

Borrelia burgdorferi transmitted via Ixodes tick

What are the 3 stages of Lyme disease?

Stage 1: early localized

Stage 2 :early disseminted

Stage 3 :late disease

What is the name of the classic rash of Lyme disease?

Erythema migrans

What's stage will you see an initially erythematous macule or papule that

expands centrifugally to form a target shaped lesion. Warm to touch and can be up to 15cm. Can appear up to 30 days after tick bite (avg 7-14 days). Pt can experience burn, pruritic, pain along with F, chills, myalgia, HA, weakness and photophobia.

Stage 1: Early localized

(Erythema migrans 80%)

Initially Red macular-papular rash, expanding over days-weeks with central clearing and blanching. This describes the rash of which viral condition?

Lyme disease

This stage happens 1-12 weeks later after multiple EM's may be present and the patient can experience neurological symptoms like cranial nerve palsies (Bells Palsy), HA, aseptic meningitis, weakness, cardiac issues (AV block).

Stage 2: Early Disseminated Lyme Disease

This stage occurs months to years after Lyme infection. The patient can experience intermittent or persistent arthritis in the large joints. Additionally, persistent neurologic symptoms such as confusion, disorientation and lack of concentration

Stage 3 Late Lyme Disease

How much time must pass between tick exposure and blood testing for Lyme disease?

4 weeks

What is the initial test for diagnosis of Lyme disease?

ELISA

What does the ELISA test for Lyme disease (LD) look for?

Antibodies to B. burgdorferi

If the ELISA test is positive, what is the next step to confirm dx?

Western blot

You perform a Western blot on a patient whose ELISA was positive for B. burgdorferi antibodies. The results of the western blot are + for IgM and - for IgG. What is the next appropriate step?

Repeat the test in a month

If only IgM is positive still after 1 month, ELISA was a false positive

What is the prophylactic treatment of LD?

Single dose of doxycycline within 72 hours of tick removal

What is the treatment for active LD?

Doxycycline for 14-21 days

_alternatives to Doxy in the treatment of LD

Amoxicillin or cefuroxime

What are the circumstances in which Amoxicillin would be chosen over Doxycycline for the treatment of LD?

Patient < 8 y/o

Patient allergic to doxy

Patient is pregnant

If LD is severe, we can give?

IV Ceftriaxone

Chronic granulomatous disease affects superficial tissues (skin & peripheral nerves). The incubation few months to 20-50 years.

Leprosy (Hansen's Disease)

Leprosy is more common in cooler areas of skin, such as ___ and ___

Peripheral nerves and testes

What are the two types of leprosy?

1. Paucibacillary leprosy (tuberculoid)

2. Multibacillary leprosy (lepromatous)

More mild leprosy characterized by localized 5 or few skin skin lesion. Sharply demarcated hypopigmented macular lesions/plaques with well-defined erythematous purple borders. There is a loss of sensation (advanced lesion) with atrophic center.

Paucibacillary leprosy (tuberculoid)

Paucibacillary leprosy causes a sudden onset of _______. Usually the numbness will first start will temperature sensation loss followed by light touch, pain, and the deep pressure

asymmetric nerve involvement

Leprosy characterized by generalized involvement including the skin, upper respiratory mucous membrane, reticuloendothelial system, adrenal glands, testes.

Lepromatous (multibacillary) leprosy

Leprosy that initially starts with hypopigmented or erythematous macules with poorly defined borders and normal sensation. It progresses to widespread infiltration with nodules and plaques. Symmetric nerve involvement with paresthesias in peripheral nerves

Lepromatous (multibacillary) leprosy

Thickening of forehead, loss of eyebrows and eyelashes, distortion of the nose, thickened earlobes. What type of facies is this and is seen in what disease?

Leonine facies in Lepromatous Leprosy

How do you dx Leprosy ?

One or more of the following:

1. From endemic area

2. Skin lesions characteristic of disease

3. Enlarged peripheral nerve

4. Loss of sensation or diminishment of

5. Biopsy with acid fast bacillus smear or PCR

MC sexual transmitted infection

HPV

How do you tx Tuberculoid Leprosy ?

Dapsone plus rifampin x 6 m

How do you tx Lepromatous Leprosy ?

Dapsone + rifampin + clofazimine x 1 year

Uncommon form of extrapulmonary TB. Cutaneous infection through exogenous or

endogenous innoculation. Presents with a wide array of presentations that depends on route of inoculation and immune status.

cutaneous TB

What is in the classification of Exogenous CTB ?

1. Primary inoculation tuberculosis

(PIT)

2. Tuberculosis verrucosa cutis

Occurs at inoculated site of in nonimmune host usually through minor trauma. Can occur in mouth resulting in ulcers from bovine bacilli in unpasteurized milk.

Primary Inoculation TB

Initially 2-4 wks after inoculation a Papule forms into a painless ulcer/tuberculosis chancre with shallow granular base. Can have crust and abscess may also occur. Can resolve spontaneously or within a year and its M/C located on the upper/ lower extremities and. buttocks

Primary Inoculation TB

This CTB occurs at site of inoculation in a patient with a prior Tb infection. It Initially starts off as papule with a violaceous halo. The lesion than becomes firm, dense and takes on appearance of a verrucous plaque with irregular borders. It is painless. Its MC on the dorsolateral hands and fingers. On children its MC on the lower extremities/knees

Tuberculosis verrucosa cutis

What is the tx for CTB?

RIPES

1. Rifampin

2. Isoniazid

3. Pyrazinamide

4. Ethambutol

5. Streptomycin

(need to tx with two of these)

Infects epithelial tissues of skin and mucous membranes causing slow growing hyperplastic keratinzation

HPV

What is the MC STI in the US?

HPV

What is the most common presentation of HPV

Warts

Common wart is known as ____

Verruca vulgaris

Firm, hyperketatotic papules with "bleeding points" (thromboses capillaries) and disruption of normal skin lines. Most commonly found on hands and feet that can be transmitted via Skin to Skin contact or Fomites.

Verruca vulgaris

What are the "bleeding points" of the common wart?

Thrombosed capillaries

Flat topped, flesh-pink warts commonly found on the face and extremities

Verruca plana

Method of treatment for warts in which liquid nitrogen is used to freeze the wart

Cryotherapy

What is used for cryotherapy in the treatment of warts?

Liquid nitrogen

What is ILC in the treatment of warts?

Intra-lesional candida. Candida is injected into the wart to kick start the immune system to fight the candida, and thus allowing it to fight the HPV

Acantholytic agent used in the treatment of warts. Creates a water blister between the epidermis and dermis, separating the layers of skin, breaking the wart off

Cantharone

Where does Cantharone come from?

Beetle juice extract

What patient population is Cantharone good for in the treatment of warts and why?

Children, because it is much less painful than cryotherapy

When treating a child for warts, what is the least painful treatment option?

Cantharone

How does Cantharone work?

Creates a water blister between the epidermis and dermis, separating the layers of skin, breaking the wart off

HPV infection to anogenital areas and/or oropharynx

Condyloma Acuminatum

Painless papules that evolve into soft, fleshy cauliflower-like cluster lesions on the genitals, personal area or oropharynx

Condyloma

What is the causative agent of condyloma?

HPV

Left untreated, condyloma can lead to ___

Cervical dysplasi/carcinoma

What are the HPV strain responsible for causing cervical cancer?

16, 18, 31, 33, 35

Who gets Condyloma acuminatum?

M/C AA

Unprotected sex

Ages 18-59

What can you use to apply to the HPV lesion and if it is HPV it will turn the lesion white.

3-5% Acetic acid

How do you dx Condyloma Acuminatum ?

Clinical BUT biopsy for HPV DNA

What is the tx for Condyloma Acuminatum ?

1. Imiquimod TIW x 16 weeks max

2. Podofilox

3. Cryotherapy

4. Gradle/cautery

Benign viral infection that can occur anywhere on the body but spares palms and soles. Commonly seen on trunk, a.c & popliteal fossae, crural folds, and axilla.

Molluscum contagiosum

What is the causative agent of molluscum contagiosum?

Poxvirus

Children swimming together may precipitate the spread of which common pediatric viral condition?

Molluscum contagiosum

Flesh colored firm dome shaped waxy papules with central

umbilication is characteristic of ____

Molluscum contagiosum

Molluscum Contagiosum MC seen in?

Children

On a biopsy of a molluscum contagiosum lesion, you would find ____

Inclusion bodies

tx of Molluscum Contagiosum

is benign, self limiting (resolves in 12-18 months), no treatment needed

Acute reactivation of Varicella Zoster Virus (VZV) that causes pain, burning, or paresthesias usually before the rash develops by a few days. The rash is characterized by being unilateral and dermatomal that starts as papules/plaques of erythema and progresses to vesicles/ bullae that eventually are pustules that crust up and heal.

herpes zoster (shingles)

What is at risk for Herpes Zoster?

1. Advanced age (>50)

2. Immunocompromised

Can contract VZV from direct contact with _____ from _____ and from _______

fluid; vesicles; airborne transmission

Who must be avoided at all costs to prevent transmission of herpes zoster?

1. pregnant

2. immunosuppressed

3. unvaccinated

Herpes Zoster is no longer contagious once lesions crust usually within _____ days

7-10 days

Provides rapid diagnosis of HSV or VZV

Tzanck smear

What is a limitation of the Tzanck smear?

Cannot differentiate HSV-1 and HSV-2

What is the preferred when testing is needed to confirm Herpes Zoster?

PCR

Gimesa/Wright stain reveals a multinucleate giant cell with which conditions?

HSV or VZV

What would you expect to see on Gimesa/Wright stain of a HSV lesion?

Multinucleated giant cells

What is the treatment of choice for herpes zoster?

PO Valcyclovir (Valtrex)

+/- Prednisone depending on severity

What is a complication of herpes zoster?

Post herpetic neuralgia (pain > 90 days after onset)

What is a treatment for post-herpetic neuralgia?

Gabapentin (Neurontin)

Zoster affecting V1 of the Trigeminal Nerve (CN5) that affect the ophthalmic division BUT further divided into: frontal, lacrimal, nasociliary nerve.

Herpes Zoster Ophthalmalicus