LIFE-THREATENING DERMATOSES DERMATOSES Patricia Treadwell, M.D. Professor of Pediatrics Professor of Pediatrics IU School of Medicine UK H UK Health Care lth C
Faculty Disclosure Faculty Disclosure Novartis PI for research study Novartis- PI for research study Eli Lilly & Co- spouse has stocks I do intend to discuss an unapproved/investigative use of FDA approved products in my presentation . pp p y p
Practice Gap Practice Gap Cutaneous findings are sometimes the first Cutaneous findings are sometimes the first clue to a life-threatening disorder. Practitioners are not always cognizant of Practitioners are not always cognizant of the diseases associated with the cutaneous findings and proper diagnosis may be findings and proper diagnosis may be delayed.
Objective Objective This presentation will highlight the This presentation will highlight the cutaneous findings in staphylococcal scalded skin syndrome toxic shock scalded skin syndrome, toxic shock syndrome, meningococcemia, RMSF, Steven’s Johnson Syndrome and Kawasaki Steven s Johnson Syndrome and Kawasaki disease. Recognition of the findings will allow for prompt diagnosis allow for prompt diagnosis.
Expected Outcome Expected Outcome The attendees should be able to recognize The attendees should be able to recognize skin changes in these disorders and appropriately recommend further work up appropriately recommend further work-up and treatment following this session. Patient outcomes will be improved through Patient outcomes will be improved through the acquisition of this knowledge.
STAPHYLOCOCCAL SCALDED SKIN SYNDROME SCALDED SKIN SYNDROME Exfoliatin toxin Exfoliatin toxin Colonization with S.aureus usually phage type II II Primarily children under 5 years of age Renal disease contributes to poor clearance of the toxin
SSSS CLINICAL FINDINGS CLINICAL FINDINGS Generalized erythema with flexural Generalized erythema with flexural accentuation Skin tenderness Ski d Flaccid bullae in the intertriginous areas Exfoliation Positive Nikolsky’s sign Positive Nikolsky s sign Later desquamation
SSSS THERAPY THERAPY Maintain fluid status Maintain fluid status Prevent secondary infection Systemic anti-staphylococcal antibiotic
REFERENCES REFERENCES Blyth M et al: Severe Stapylococcal Blyth M, et al: Severe Stapylococcal Scalded Skin Syndrome in Children. Burns 2008;34:98 103 2008;34:98-103. Chang P, et al: Picture of the Month. Staphylococcal Scalded Skin Syndrome. S h l l S ld d Ski S d Arch Pediatr Adolesc Med 2008;162:1189- 1190 1190.
REFERENCES REFERENCES Norbury WB et al: Neonate Twin with Norbury WB, et al: Neonate Twin with Staphylococcal Scalded Skin Syndrome from a Renal Source Pediatr Crit Care from a Renal Source. Pediatr Crit Care Med 2010;11:e20-23. Patel NN, et al: Staphylococcal Scalded P l NN l S h l l S ld d Skin Syndrome. Am J Med 2010;123:505- 507 507.
TOXIC SHOCK SYNDROME TOXIC SHOCK SYNDROME Toxic shock syndrome toxin TSST 1 Toxic shock syndrome toxin TSST-1 Staphylococcal enterotoxins Streptococcal toxin Other toxins
TOXIC SHOCK SYNDROME CASE DEFINITION CASE DEFINITION Fever Fever Erythema Desquamation, 1-2 weeks after the onset of the illness, particularly of the palms and soles Hypotension (systolic BP <90 for adults yp ( y and <5th percentile for age for children <16 years of age, or orthostatic syncope) y g , y p )
TOXIC SHOCK SYNDROME- CASE DEFINITION (cont) CASE DEFINITION (cont) Involvement of 3 or more of the following: Involvement of 3 or more of the following: Gastrointestinal (vomiting or diarrhea Muscular (severe myalgia or high CK) M l ( l i hi h CK) Mucous membrane hyperemia Renal (sterile pyuria , high BUN or CR) Hepatic (high bili, SGOT< or SGPT) Hematologic (low platelets) CNS (disorientation)
TOXIC SHOCK SYNDROME TOXIC SHOCK SYNDROME Cutaneous findings Cutaneous findings -erythema -conjunctival injection conjunctival injection -necrolysis -multiple pustules multiple pustules -desquamation
TOXIC SHOCK SYNDROME- TREATMENT TREATMENT Supportive therapy including maintaining Supportive therapy-including maintaining fluid status and use of vasoactive agents as necessary necessary Adequate drainage of suppurative sites Anti-staphylococcal antibiotics
REFERENCES REFERENCES Alwattar BJ et al: Streptococcal Toxic Alwattar BJ, et al: Streptococcal Toxic Shock Syndrome Presenting as Septic Knee Arthritis in a 5 year old Child J Pediatr Arthritis in a 5-year-old Child. J Pediatr Orthop 2008;28:124-127. Berk DR, et al: MRSA, Staphylococcal B k DR l MRSA S h l l Skin Syndrome, and Other Cutaneous B Bacterial Emergencies. Pediatr Ann i l E i P di A 2010;39:627-633.
REFERENCES REFERENCES Chan KH et al: Toxic Shock Syndrome and Chan KH, et al: Toxic Shock Syndrome and Rhinosinusitis in Children. Arch Otolaryngol Head Neck Surg Otolaryngol Head Neck Surg 2009;135:538-542. Todd JK: Toxic Shock Syndrome-Evolution T dd JK T i Sh k S d E l i of an Emerging Disease. Adv Exp Med Biol 2011 697 175 181 2011;697:175-181.
MENINGOCCEMIA MENINGOCCEMIA Patients present with fever myalgias Patients present with fever, myalgias and malaise Sometimes may see meningismus Skin lesions - macules, petechiae, and purpuric lesions with jagged edges Profound hypotension and shock can occur with overwhelming infections occur with overwhelming infections
MENINGOCCEMIA MENINGOCCEMIA DIC may develop DIC may develop Complications of DIC include Complications of DIC include thromboses or gangrene
MENINGOCCEMIA - TREATMENT TREATMENT Isolation Isolation Supportive therapy including fluids and vasoactive agents as necessary Systemic penicillin Systemic penicillin Cefotaxime and ceftriaxone are alternatives If patient has anaphylactoid-type penicillin reaction may use chloramphenicol reaction, may use chloramphenicol
MENINGOCCEMIA MENINGOCCEMIA Evaluate need for treatment of household Evaluate need for treatment of household members and close contacts
REFERENCES REFERENCES Agarwal MP et al: Clinical Images: Purpura Agarwal MP,et al: Clinical Images: Purpura Fulminans caused by Meningococcemia. CMAJ 2010;182:E18 CMAJ 2010;182:E18. Klinkhammer MD, et al: Pediatric Myth: F Fever and Petechiae. CJEM 2008;10:479- d P hi CJEM 2008 10 479 482.
ROCKY MOUNTAIN SPOTTED FEVER SPOTTED FEVER Ca sed b Ri k tt i Caused by Rickettsia rickettsii i k tt ii Typically history of tick exposure Incubation 2-14 days
ROCKY MOUNTAIN SPOTTED FEVER SPOTTED FEVER Fever Fever Severe headache Confusion Nausea and vomiting Photophobia
ROCKY MOUNTAIN SPOTTED FEVER SPOTTED FEVER - exanthem exanthem Exanthem present in 90 % patients Exanthem present in 90 % patients Erythematous macules and papules initially Later, petechial or purpuric lesions Lesions occur initially on the palms and y p soles, then spread centrally
ROCKY MOUNTAIN SPOTTED FEVER SPOTTED FEVER Supportive therapy may be necessary Supportive therapy may be necessary Doxycycline Chloramphenicol
ROCKY MOUNTAIN SPOTTED FEVER-References FEVER References Davis RF et al: Recognition and Davis RF, et al: Recognition and Management of Common Ectoparasitic Diseases in Travelers Am J Clin Dermatol Diseases in Travelers. Am J Clin Dermatol 2009;10:1-8. Miniear TD, et al: Managing Rocky Mi i TD l M i R k Mountain Spotted Fever. Expert Rev Anti I f Infect Ther 2009;7:1131-1137. Th 2009 7 1131 1137
REFERENCES REFERENCES Usatine RP et al: Dermatologic Usatine RP, et al: Dermatologic Emergencies. Am Fam Physician 2010;82:773 480 2010;82:773-480.
HENOCH-SCHONLEIN PURPURA PURPURA A hypersensitivity reaction that occurs A hypersensitivity reaction that occurs typically following an infection Infection most often streptococcal or viral
HENOCH-SCHONLEIN PURPURA PURPURA Palpable purpura Palpable purpura Petechial lesions Acral distribution Vesicular or bullous lesions Infants tend to have more involvement of the face and scalp with accompanying edema
HENOCH-SCHONLEIN PURPURA PURPURA Gastrointestinal abnormalities Gastrointestinal abnormalities – including abdominal pain, vomiting and bloody stools and bloody stools Arthralgias and/or arthritis Arthralgias and/or arthritis Renal abnormalities
HENOCH-SCHONLEIN PURPURA PURPURA Immune complex formation Immune complex formation Histology shows leukocytoclastic Histology shows leukocytoclastic vasculitis with extravasated RBC’s Immunofluorescence shows IGA
HENOCH-SCHONLEIN PURPURA PURPURA Treatment Treatment Elevation Anti inflammatory medication Anti-inflammatory medication Corticosteroid controversy Renal status should be monitored if h if there is evidence of renal disease i id f l di in the acute stages
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