Category: Dermatology

Podcast # 349: Fat Emboli

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Author: Sue Chilton, MD

Educational Pearls:

  • Triad of fat emboli syndrome is a petechial rash, AMS, and respiratory distress.
  • Petechiae usually start in the axilla.
  • 90% of patients with long bone fractures will shed fat.
  • May see ground-glass opacities on imaging, but perfusion defects will not be seen on CTA or V/Q scan
  • Patients with a PFO can have cerebral involvement.

 

References

Newbigin K, Souza CA, Torres C, Marchiori E, Gupta A, Inacio J, Armstrong M, Peña E. Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings. Respir Med. 2016.113:93-100. doi: 10.1016/j.rmed.2016.01.018.

Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation. 2015. 20;131(3):317-20. doi: 10.1161/CIRCULATIONAHA.114.010835.

Podcast #238: Honey and Burns

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Author: Nick Hatch, M.D.

Educational Pearls

  • Honey can be used to treat burns because it has antibacterial properties. In one study, honey outperformed silver sulfadiazine for burn treatment, but more research is needed in this area.
  • In practice, honey is likely more useful outside the ER than inside the ER.

References: Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey Dressing Versus Silver Sulfadiazene Dressing for Wound Healing in Burn Patients: A Retrospective Study. Journal of Cutaneous and Aesthetic Surgery. 2011;4(3):183-187. doi:10.4103/0974-2077.91249.

Podcast #169: Lyme Disease

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bd9fdb03-4845-4c2d-b1fc-f4bcd1253d7cRun Time:  7 minutes

Author: Greg Burcham M.D.

Educational Pearls:

  • Case presentation: A 48 year-old male cyclist travels to new england for a race. Afterwards he is sore, tired and fatigued, but 1 week later back in Colorado he is still sore, tired, and fatigued, and he also noticed a rash that started after a few days. The patient presents to the ED after a syncope with HR in the low 40s.
  • This patient has Lyme Disease. Hallmarked by the rash that he has, known as erythema migrans – a migrating red rash.
  • Symptoms usually present 1-2 weeks after a tick bite, and generally start as nonspecific – fever, myalgias, headache, arthralgias, malaise. 80% of patients present with the rash that starts as a small red lesion that enlarges with a bright red border.
  • A smaller percentage of patient get early disseminated disease. The most concerning complications are cardiac – Atrioventricular Block, bradycardia, and syncope – or a meningitis presentation.
  • Late disseminated findings include chronic joint and muscle arthralgias, seizures, paresthesias, memory and cognitive changes. Amy Tan – author of The Joy Luck Club – has chronic lyme and she loses memory if she is off her antibiotics for any period of time.
  • Lyme Disease is increasing by more than 10% per year for several years due to the destruction of habitat of predators, leading to mice population explosion, and global warming.
  • Each stage of the tick life cycle require a blood meal – larva to nymph to adult. Normally larva find it hard to get a blood meal in the fall after they hatch in the late summer. The larva go dormant until spring when they are able to find a blood meal and eventually become adults so the life cycle can start over on an annual basis.
  • As the climate has warmed a higher percentage of larvae are feeding earlier in the year, with a greater frequency in the New England area.
  • The bacteria that causes Lyme Disease needs time to replicate in the host, but due to asynchronous feeding between the mice and ticks there is a higher concentration of the bacteria in both the mice and the ticks.

Link to Podcast: http://medicalminute.madewithopinion.com/lyme-disease/

References: http://rstb.royalsocietypublishing.org/content/370/1665/20140051

https://www.cdc.gov/lyme/

Podcast #142: Botulism from Black Tar Heroin

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1a8507d2-51ff-4a3f-a362-e31140ac1d49Run Time: 2 minutes

Author: Michael Hunt M.D.

Educational Pearls:

  • The first case of skin botulism from the use of black tar heroin in Colorado was documented in July of 2016.
  • Botulism is most deadly toxin known to man and originates from the genus of tetanus and difficile – Clostridium botulinum.
  • Characteristics of botulinum, bulbar palsies of the cranial nerves causes a descending paralysis from the head down.
  • Neurologic symptoms start as decreased facial sensation, EOMI problems, difficulty controlling airway, skeletal muscle dysfunction, and diaphragm dysfunction.
  • Patients with botulism from heroin use need to be admitted to the ICU. Treatment includes airway support and management, then administration of the antitoxin from the CDC.

Link to Podcast: http://medicalminute.madewithopinion.com/botulism-from-black-tar-heroin/

References: http://www.tchd.org/DocumentCenter/Home/View/3591

https://www.cdc.gov/botulism/index.html

 

Podcast #97: Cellulitis

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e542f32d-6f54-4492-a08c-da7bc2755ec7Run Time: 2 minutes

Author:  Ian Gillman PA-C

Educational Pearls:

  • While cellulitis is a very common condition seen in the ER, there are other conditions that can mimic cellulitis.
  • Some of these conditions are gout, pseudogout, erythema migrans, gas gangrene, osteomyelitis, and necrotizing fasciitis.
  • An ultrasound can be performed to confirm cellulitis, which would be indicated by cobble-stoning on the image (indicated in image below).
  • Treatment and management include antibiotic therapy and marking the area of redness to follow any progression of the cellulitis.

image-11-608x400

Link to Podcast:  http://medicalminute.madewithopinion.com/cellulitis/

References:  http://emedicine.medscape.com/article/2012280-overview

Podcast #79: Fifth Disease

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Run Time: 7 minutes

Author: Dr. Samuel Killian

Educational Pearls:

  • Presentation: A fever and nasal congestion that began in an infant one week ago but has resolved. A rash that was predominantly over the cheeks but has spread to the rest of the body. No pain with the rash, just blistering.
  • Diagnosis: Fifth disease or erythema infectiosum, which it is caused by parovirus B19. This disease’s first phase starts with “slap-cheek” rash that lasts 1-4 days, which moves to the extremities and then to the trunk. The second phase consists of the formation of a reticular rash. In the third phase, the rash comes and goes depending on whether and activity.
  • Around 75% of people have parovirus B19 in their body, although it is almost always benign.
  • The virus can cross both the brain-barrier and the placental-barrier, causing complications in people with thalassemia and women who are pregnant.
  • 1 to 9 of all miscarriages are believed to be caused by this parovirus.

Link to Podcast: http://medicalminute.madewithopinion.com/fifth-disease-1/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793222/

http://www.ncbi.nlm.nih.gov/pubmed/2160748

Podcast #77: Purpura

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c5f8db53-cbd5-4959-bf81-da4c457765c1Run Time: 14 minutes

Author: Dr. Donald Stader

Educational Pearls:

  • When a patient comes in with purpura the way to think is outside in, because there is a long list of things that can cause purpura.
  • The most common cause of purpura is trauma.
  • The next level is a blood vessel problem; Ehler’s-Danlos Syndrome, Vitamin C deficiency.
  • Coagulation disorders is the 3rd level; hemophilia, coagulopathy (drugs are a big cause), low platelet counts (such as ITP)
  • The most serious problems are often acquired and purpura could be a potentially deadly manifestation – such as HUS (caused by E. coli O157:H7), bacterial meningitis (meningococcus), leukemia/lymphoma, HSP.
  • Often children are more seriously affected when they have purpura – importnant to check CBC, PT INR, and a BMP to evaluate for kidney function.

Link to Podcast:  http://medicalminute.madewithopinion.com/purpua/

References:  http://www.aafp.org/afp/2008/0415/p1117.html

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Podcast #71: Pityriasis Rosea

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4657fd9f-14d1-44c7-9e65-8dfcf2ba93aeIMG_1516Run Time: 4 minutes

Author: Dr. Samuel Killian

Educational Pearls:

  • Pityriasis rosea is a papulosquamous rash believed to be caused by a virus (although no one has identified the agent) presenting with a salmon-colored patch followed by the presentation of lesions that follow the cleavage lines forming a “christmas tree” pattern.
  • Treatment is supportive with antihistamines and topical steroids.

Link to Podcast:  http://medicalminute.madewithopinion.com/pityriasis-rosea/

References:  http://emedicine.medscape.com/article/1107532-overview

 

Podcast #52: Syphilis the Great Imitator

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Run Time: 7 minutessyphilis-hands

Author: Dr. Donald Stader

Educational Pearls:

  • Syphillis is a very important historical and current disease. The study of Syhpillis or “Syphilology” evolved into the field of dermatology.
  • Syphilis, an is caused by the spirochete bacteria, Treponema pallidum. 
  • Syphilis comes in three stages: primary, secondary, and tertiary stages.
  • In the primary stage, they develop a canker that is a painless ulcerative lesion on the genitals, mouth or anus and resolves over time.
  • In the next few weeks you begin the secondary stage of syphilis marked by the development of a rash – that can  mimic any rash except those with vesicles – classically it involves the hands and soles of the feet.
  • The tertiary stage occurs over many years, it has many manifestations including neurosyphilis – which can cause psychosis, dementia or even stroke symptoms. People with tertiary stage syphilis also develop a proximal aortic aneurysm, called a “leutic aneurysm” causing aortic regurgitation. This has a ton of clinical signs and can manifest in the bouncing of someones head, pulsating hands, and blushing of nail beds with each beat of the heart. Tertiary stage syphilis can also cause hepatitis and even give people “gummas”, which are rubbery lesions to peoples skin. Bottom line – Syphillis causes a ton of symptoms and has been called the “Great Imitator” as a result.
  • Treatment of syphilis is penicillin, which is the best antibiotic to treat the infection. Depending on the stage and length of time the person has had syphilis dictates how long of a treatment regimen they will be placed on.
  • For those allergic to penicillin with neurosyphilis, people can undergo a process of developing anergy to be able to tolerate penicillin. This is usually done in conjunction with an immunologist.
  • In the United States, Baltimore and Louisiana have higher rates of syphilis than the rest of the country.

Link to Podcast: http://medicalminute.madewithopinion.com/syphillis-the-great-imitator/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88914/

For your intrigue: http://www.theatlantic.com/health/archive/2015/12/the-return-of-syphilis/418170/

Podcast #24: Stevens-Johnson Sydrome/ TENS

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a1f73a72-7248-488a-a23f-1fe7baba50cbRun Time: 7 minutes

Author: Dr. Donald Stader

Educational Pearls:

  • Stevens-Johnson Syndrome (SJS) was first described in 1922 by pediatricians Dr. Stevens and Dr. Johnson after severe rash and skin peeling in one of their patients.
  • SJS is described on a scale of <10% of body affected is Steve-Johnson Syndrome, 10%-30% is called Steven-Johnson/TENS, and >30% is called TENS (Toxic Epidermal Necrolysis).
  • The CD48 T-cells and natural killer cells attack the skin at the dermal-epidermal junction after drug trigger or infectious trigger – the body thinks its own cells are toxic.
  • Patients are affected with mainly mouth and eye symptoms before a rash erupts that progress from red to blistering to sloughing.
  • Patients are cared for like burn patients, but in the ER do not need as much fluid as burn patients.
  • The majority of mortality is due to either Psuedomonas or Staph infections.

Link to Podcast:  http://medicalminute.madewithopinion.com/stevens-johnson-syndrome-tens/

References:  http://www.dermnetnz.org/reactions/sjs-ten.html