DailyReview Flashcards
HBsAg: negative anti-HBc: negative anti-HBs: negative
Susceptible
HBsAg negative anti-HBc positive anti-HBs positive
Immune due to natural infection
HBsAg negative anti-HBc negative anti-HBs positive
Immune due to hepatitis B vaccination
HBsAg positive anti-HBc positive IgM anti-HBc positive anti-HBs negative
Acutely infected
HBsAg positive anti-HBc positive IgM anti-HBc negative anti-HBs negative
Chronically infected
HBsAg negative anti-HBc positive anti-HBs negative
Interpretation unclear; four possibilities: 1. Resolved infection (most common) 2. False-positive anti-HBc, thus susceptible 3. “Low level” chronic infection 4. Resolving acute infection
The hallmark of ongoing Hepatitis B infection
persistence of surface antigen and absence of surface antibody.
Diagnosis of diabetes
- Fasting glucose > 126 mg per deciliter (7.0 mmol per liter)
- A1C > 6.5% or more
- Confirmation by the same or the other test.
- OGTT 2-hour > 200 mg per deciliter (11.1 mmol per l); loading dose of 75 g
- 100 < Fasting glucose <= 125 mg (5.6 to 6.9 mmol per liter) is prediabetes;
- A1C criteria for prediabetes, ADA: 5.7 to 6.4%.
Why is prandial insulin the right strategy for steroid driven hyperglycemia?
Glucocorticoids impair glucose transport into cells; decrease islet cell function.
Glucocorticoids drive up post-prandial blood sugars much more than fasting glucose. So glucorticoid induced hyperglycemia is best treated by adjusting prandial insulin
Herpes Zoster vaccine: age
> 60
All without contraindications
Epinephrine in anaphylaxis
- Not profoundly hypotensive: 0.01 mg/kg IM into mid outer thigh, max dose 0.5 mg
- Profoundly hypotensive: slow IV at 0.1 mcg/kg/minute, and increase it every two to three minutes by 0.05 mcg/kg/minute until blood pressure and perfusion improve
The epinephrine dilution for IM injection contains 1 mg/mL and ampules may also be labeled as 1:1000.
Epinephrine is commercially available in several dilutions. Great care must be taken to use the correct dilution in order to avoid overdosing the patient [35]. To prepare an epinephrine IV maintenance infusion, the commercially available epinephrine solution (eg, ampule, syringe) must be further diluted. To reduce the risk of making a medication error, we suggest that centers have a protocol available that includes steps on how to prepare and administer an epinephrine infusion.
- A simple method for quickly preparing a solution of 1 mcg/mL for adults and adolescents is to add the entire 10 mL contents of a 0.1 mg/mL (1:10,000) prefilled “cardiac” epinephrine syringe (1 mg) to a 1000 mL (1 liter) bag of normal saline. The resultant solution of 1 mcg/mL delivers 1 mcg/minute of epinephrine for each 60 mL/hour of solution infused. Therefore, 120 mL/hour will deliver 2 mcg/minute and so forth (table 3).
- For adolescent/adult patients who have already received large quantities of IV fluids (four or more liters), a more concentrated solution (4 mcg/mL) is preferable. Using a more concentrated solution allows titration of epinephrine infusion and administration of bolus crystalloid solution to be done independent of one another. To prepare a 4 mcg/mL solution, add the entire 10 mL contents of one 0.1 mg/mL (1:10,000) epinephrine syringe to a 250 mL bag of normal saline. The resultant solution delivers 1 mcg/minute of epinephrine for each 15 mL/hour of infusion. Therefore, 30 mL/hour delivers 2 mcg/minute, 45 mL/hour delivers 3 mcg/minute, and so forth (table 4).
•
Early ejection click + soft systolic murmur in 2 RICS
Bicuspid aorta
A functionally normal bicuspid aortic valve produces an ejection sound or click heard best at the left lower sternal border or apex, often accompanied by a brief ejection murmur. Diagnosis is by TEE.
Bicuspid aortic valve risks
AS, Infective endocarditis, aortic dilation, aortic dissection
significant aortic stenosis much more frequently than significant aortic regurgitation and are at risk for infective endocarditis. (See ‘Valve disease’ above.)
●Patients with bicuspid aortic valve are at risk for aortic dilation (most commonly involving the ascending aorta) and aortic dissection. These aortic complications are caused by an underlying aortopathy with cystic medial degeneration as well as hemodynamic factors and abnormal aortic wall shear stress. (See ‘Aortic dilation and aortic dissection’ above and ‘Pathophysiology of aortic disease’ above.)
●A bicuspid aortic valve is frequently associated with other congenital cardiovascular defects, including coarctation of the aorta, supravalvular aortic stenosis, subvalvular aortic stenosis, ventricular septal defect, and sinus of Valsalva aneurysm. The combination of bicuspid aortic valve and coarctation of the aorta is associated with high risk of aortic complications. (See
AS versus aortic sclerosis murmur
Sclerosis murmur: brief, not loud
Aortic sclerosis, in the absence of stenosis, may be associated with a midsystolic ejection murmur, which is usually best heard over the right second interspace. In general, the murmur is brief and not very loud. Importantly, many patients with aortic sclerosis have no murmur on physical examination.
A normal carotid pulse and normal S2 suggest the absence of aortic stenosis (figure 1). (See “Auscultation of cardiac murmurs in adults”.)
However, the physical examination is neither sensitive nor specific for excluding aortic valve obstruction. Thus, echocardiography should be performed to distinguish aortic sclerosis from aortic stenosis and other cardiac abnormalities that might account for the murmur when present.
HOCM murmur
Harsh ejection murmur increasing with Valsalva
Live vaccines should either be given together or at least _ weeks apart
4
T1 vs T2
CSF is dark on T1-weighted imaging and bright on T2-weighted imaging.
Anatomy.radiculopathies
Weakness biceps, brachioradialis; numbness medial half of hand; absent biceps reflex?
C6
bi6
Live vaccines
- MMR;
- varicella-zoster (chickenpox);
- Shingles, influenza (intranasal)
Vertigo without hearing loss
Vestibular neuronitis
Labyrinthitis is a similar syndrome to vestibular neuritis, but with the addition of hearing symptoms (sensory type hearing loss or tinnitus). The symptoms of bothvestibular neuritis and labyrinthitis typically include dizziness or vertigo, disequilibrium or imbalance, and nausea. Acutely, the dizziness is constant.
Bronchiectasis, recurrent sinopulmonary infections + infertility
cystic fibrosis
Forms of varicella zoster infection
- Chicken pox
- Shingles
Primary infection with VZV results in varicella (chickenpox), characterized by vesicular lesions in different stages of development on the face, trunk, and extremities.
Herpes zoster, also known as shingles, results from reactivation of VZV infection within the sensory ganglia.
Cx: painful, unilateral vesicular eruption in a dermatome
Warfarin and enoxaparin: minimum overlap period
5 days
Jugular cannon waves + variable S1
Ventricular tachycardia
Axonal vs demylinating neuropathy
- Demyelinating: slow conduction
- Axonal: reduced amplitude of evoked compound action potentials with relative preservation of the nerve conduction velocity.
Electrodiagnostic studies can determine if the disorder is due to a primary nerve (neuropathy) or muscle disorder (myopathy). These tests also can identify whether the patient’s symptoms are secondary to a polyneuropathy or another peripheral nerve disorder (eg, polyradiculopathy from lumbar stenosis); if it is a polyneuropathy, EMG/NCS will reveal whether it is axonal or demyelinating in character. The clinical examination alone generally cannot make the latter distinction.
Electrodiagnostic features of demyelinating disorders include:
●Slow nerve conduction velocity
●Dispersion of evoked compound action potentials
●Conduction block (decreased amplitude of muscle compound action potentials on proximal compared with distal nerve stimulation)
●Marked prolongation of distal latencies
In contrast, axonal neuropathies are characterized by a reduced amplitude of evoked compound action potentials with relative preservation of the nerve conduction velocity.
Vaccines: It is not necessary to restart an interrupted vaccine series (except _ _)
oral typhoid
Vaccines: implication of local reaction and fever
Not a CIxn
Meta: CIxn
Many vaccines cause a local reaction and fever that lasts 24 to 48 hours. This does not contraindicate using the vaccine again and should not be considered an allergic response.
Vaccines: Influenza: Efficacy
60% to 80% effective in preventing disease, but 95% effective in preventing complications
NNV: 71 - 40
In a 2014 meta-analysis of randomized trials and observational studies of healthy adults, the overall efficacy of inactivated vaccines in preventing laboratory-confirmed influenza was 60 percent (53 to 66 percent), corresponding to a number needed to vaccinate (NNV) of 71 [28]. The overall effectiveness of inactivated vaccine against influenza-like illness was 16 percent (95% CI 5 to 25 percent), corresponding to a NNV of 40
Because influenza vaccines produced in eggs take approximately six months to manufacture, they necessarily contain antigens from strains that circulated during the previous year. The protective efficacy of the vaccine is largely determined by the relationship (closeness of “fit” or “match”) between the strains in the vaccine and viruses that circulate in the outbreak. A study that compared the effectiveness of the inactivated influenza vaccine during influenza seasons with differing degrees of vaccine match illustrates the importance of the fit between circulating influenza virus strains and the vaccine [37]. During the 2004 to 2005 influenza season, the antigenic match was only 5 percent compared with 91 percent during the 2006 to 2007 season, which resulted in a vaccine effectiveness of 10 versus 52 percent, respectively. During the 2014 to 2015 influenza season in the United States, influenza A H3N2 viruses predominated and more than half of these viruses contained H3N2 antigen that was antigenically different (drifted) from that included in that season’s influenza vaccines [38]. The adjusted overall vaccine effectiveness for the 2014 to 2015 influenza season was 19 percent; for H3N2-associated illness, the vaccine effectiveness was only 6 percent [39]. A meta-analysis of observational studies showed that influenza vaccines are less effective against H3N2 influenza A than against H1N1 influenza A and influenza B [40].
Influenza vaccine effectiveness in preventing laboratory-confirmed influenza in the United States is available from the Centers for Disease Control and Prevention (CDC) for influenza seasons from 2004-2005 to 2015-2016 [41].
A repeated finding in various studies is that vaccination produces a greater reduction in serologically confirmed influenza than in clinical influenza. Universal influenza vaccination in Ontario, Canada, has also been shown to reduce the number of antibiotic prescriptions during periods of peak influenza activity [42].
The primary means of assessing serum antibody responses to influenza vaccination is the serum hemagglutination (HA)-inhibition assay; in addition to the HA antibody response, other immune mechanisms that contribute to protection against influenza include mucosal immunity, antibodies to neuraminidase (NA), virus-specific CD4 and CD8 T cells, and possibly antibodies to minor envelope protein 2 (M2) and the structural nucleoprotein [3].
Healthy adults — A number of studies have evaluated the efficacy or immunogenicity of various influenza vaccines in different populations.
Trivalent inactivated vaccines — Although many studies evaluating the efficacy of influenza vaccines in healthy adults have been published and efficacy is often estimated to be between 70 and 90 percent, a 2012 comprehensive review suggested that efficacy may be considerably lower [43]. In a 2012 meta-analysis (performed by the same group that did the comprehensive review) that included eight randomized trials of the inactivated influenza vaccines in adults aged 18 to 64 years over nine influenza seasons, vaccine efficacy for preventing laboratory-confirmed influenza was 59 percent (95% CI 51 to 67 percent) [44]. Of note, higher rates of efficacy and effectiveness have been reported in trials that used serologic endpoints; such trials were excluded from this meta-analysis because using serologic endpoints is likely to lead to an overestimation of benefit.
In a 2014 meta-analysis of randomized trials and observational studies of healthy adults, the overall efficacy of inactivated vaccines in preventing laboratory-confirmed influenza was 60 percent (53 to 66 percent), corresponding to a number needed to vaccinate (NNV) of 71 [28]. The overall effectiveness of inactivated vaccine against influenza-like illness was 16 percent (95% CI 5 to 25 percent), corresponding to a NNV of 40 [28]. The difference between these two results relates to the different incidence of these endpoints among the study populations; 2.4 percent of unvaccinated individuals versus 1.1 percent of vaccinated individuals developed laboratory-confirmed influenza, whereas 15.6 percent of unvaccinated individuals versus 9.9 percent of vaccinated individuals developed an influenza-like illness, respectively. The discrepancy between protection against laboratory-confirmed influenza and influenza-like illness is likely related to the well-known lack of protection offered by influenza vaccines against non-influenza respiratory viruses.
The match between the antigens included in the influenza vaccines and circulating influenza strains would be expected to have an important influence on the efficacy of the vaccines. In the 2014 meta-analysis described above, inactivated vaccines were 16 percent effective (95% CI 9 to 23 percent) in preventing influenza-like illness when strains contained in the vaccine antigenically matched circulating strains [28]. On the other hand, inactivated vaccines were not protective against influenza-like illness when the degree of matching between the vaccine and circulating influenza strains was absent or unknown. In contrast, the efficacy of inactivated vaccines for preventing laboratory-confirmed influenza was similar when the match was good and when the match was absent or unknown (62 versus 55 percent, respectively).
Several studies have shown that influenza vaccination is less effective in individuals who were vaccinated during the current and previous season(s) compared with individuals who were vaccinated during the current season only [45-50]. Other studies have not shown a decrease in vaccine efficacy when influenza vaccination is given to people who were vaccinated the previous year [51,52].
Vaccines: Influenza: schedule
annual
Vaccines: Tdap
Td booster every 10 years
+ one Tdap
Vaccines: Varicella
2 doses at any time
Vaccines: HPV
3 doses
Age: 19-26
Vaccines: Zoster
1 dose
60 > Age
Vaccines: MMR: Schedule
(in adults)
1 dose below age 50,
1 dose above age 50 if risk factor
Vaccine: Adult: Pneumococcal: schedule
Age > 65
or
risk factor
Vaccine: Meningococcal
1 or more dose if risk factor
Vaccination: Hep A and Hep B: schedule
Only if risk factors
Hep B: 3 dose sequence,Hep A: two doses
HPV: About 70% of cervical cancers are caused by:
HPV-16 and HPV-18
MMR: CIxn
Do not give to patients who are pregnant or trying to get pregnant or to severely immunocompromised patients
HZV and Chicken-pox vaccines
Chicken pox:
Indications
All adults without evidence of immunity (Box 73-1)
Evidence of Immunity to Varicella for Adults
- Documentation of two-dose vaccine series
- Laboratory evidence of immunity
- Birth in the United States before 1980*
- Verification of history of chickenpox by a health-care provider†
- Verification of a history of herpes zoster by a health-care provider
Herpes zoster (shingles) vaccine
- Live vaccine
- About 50% to 60% effective in preventing shingles; about 60% to 70% effective in preventing postherpetic neuralgia
- Single shot; no revaccination currently recommended
- All 60 years and older
USPTF: Grading
A, B: Good; C: maybe; D: bad, I: insufficient
- A: Service recommended. Net benefit is thought to be substantial
- B: Service recommended. Net benefit is thought to be moderate to substantial
- C: Not routinely recommended. There may be some individuals for which service is appropriate
- D: Not recommended. Data show no benefit or potential for harm
- I: Current evidence insufficient to make a recommendation for or against the service
Screening: types
- Primary prevention: Intervention designed to avert disease before it develops (e.g., nutritional counseling)
- Secondary prevention: Intervention aimed at early detection of disease (e.g., mammography)
- Tertiary prevention: Preventing complications of a symptomatic disease (e.g., hepatitis B vaccine in hepatitis C patients)
Screening: ideal test properties
- Screens for a disease that has high morbidity and mortality
- Is sensitive with a confirmatory test available, inexpensive, and noninvasive
- Screens for a disease that has a long premorbid phase during which intervention can affect outcome
Screening: PSA
USPSTF recommends against screening men older than age _ years since harms outweigh benefits
USPSTF recommends against screening men older than age 75 years since harms outweigh benefits
Screening: Pap smear: frequency
- all sexually active women older than 21 years with a cervix (or within 3 years of onset of sexual activity)
- If no risk factors every 3 years
- ACS agrees but recommends three annual negative Pap smears before doing 3-year intervals.
- If no risk factors, stop after age 65
- If distant history of last Pap smear, all ages
- No Pap smears if hysterectomy for benign disease (USPTF)
Screening: Chlamydia
All asymptomatic adolescent sexually active women (24 years or younger) and high-risk adult women.
Screening: Tuberculosis
Meta: OpenQuestion
if IFN-gamma tests the same thing as skin why prefer IFN-gamma tests in BCG vaccinated patients?
Two types of tests now available: PPD and interferon-γ release assay blood test
Criteria for positive PPD test are as follows:
- Low-risk patients: 15-mm diameter or greater
- High-risk patients (any of the previous indications for screening makes a patient at least high risk): 10-mm diameter or greater
- Very-high-risk patients (HIV infection, abnormal chest film, recent contact with known infected patients): 5-mm diameter or greater
Blood test is preferred for patients who have had the BCG vaccine
Screening: hypercholesterolemia
all men 35 years or older and men and women 20 years and older if they have another risk factor for coronary heart disease
USPSTF recommends screening all men 35 years or older and men and women 20 years and older if they have another risk factor for coronary heart disease
▪
USPSTF makes no recommendation for screening women without risk factors
▪
National Cholesterol Education Program (NCEP) recommends screening all adults over age 20 years with a lipid profile
▪
Ideal frequency of screening has not been established, but NCEP recommends every 5 years if profile is normal
Screening: Abdominal aortic aneurysm (AAA)
men ages 65 to 75 years who have ever smoked
USPSTF recommends one-time screening for AAA by ultrasound in men ages 65 to 75 years who have ever smoked
Vaccines: Td
A 38-year-old recent immigrant from Vietnam comes into the emergency room after cutting his foot on a nail. He does not recall receiving any vaccines as a child. Which regimen does he need?
Three-shot dT vaccine series plus tetanus toxoid now, with first dT shot now
Chemoprevention: aspirin
if risk: benefit ration favorable then aspirin
Use of aspirin for men ages 45 to 79 years is recommended when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage
▪
Use of aspirin for women ages 55 to 79 years is recommended when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage
▪
Ideal dose is unclear since beneficial effects are shown for doses ranging from 75 mg to 325 mg
Screening: USPTF diseases
USPSTF Screening Guidelines for Common Disorders
- Obesity
- DM2
- Osteoporosis: Screen women >65 yr with a DEXA scan. Start earlier if risk factors exist
- Alcohol abuse
- Smoking
- Depression
Vaccination:
For which one of the following diseases can passive immunization with an immunoglobulin infusion not be given simultaneously with the vaccine for the disease?
Varicella
Hepatitis A
Hepatitis B
Tetanus
Varicella
Vaccination:
A 45-year-old man presents to your office in July of this year for a routine physical. He is currently drinking two six-packs of beer per day, but has no other medical problems. He believes he received all of his routine childhood vaccinations, but doesn’t recall getting any other shots since then. Which vaccine combination makes the most sense for him?
Hepatitis A, hepatitis B
Pneumococcus, meningococcus, Haemophilus influenzae
Pneumococcus, tetanus
Tetanus, influenza
Hepatitis A, hepatitis B, tetanus
Pneumococcus, tetanus
(because of EtOH use)
. Patients with chronic liver disease should be immunized against
hepatitis A and B
BMT: Vaccinations?
- Primary series dead vaccines at 12 months
- Live vaccines: after 24 months
Bone marrow transplantation patients need to be revaccinated with the primary series of all standard childhood vaccines after 12 months post-transplantation, assuming no complication from the transplantation. Live, attenuated vaccines, however, need to wait until 24 months after transplantation.
A 68-year-old gentleman with a history of hypertension and rheumatoid arthritis presents for a general medical evaluation. He says that he last had a tetanus shot 6 years ago but has not had any other immunizations in the recent past. His current medications include lisinopril 10 mg/day, prednisone 20 mg/day, and azathioprine 100 mg/day. Which of the following vaccines should be recommended?
pneumococcal vaccine, influenza vaccine.
However, he is immunosuppressed and so he should not receive any live vaccines, so the zoster vaccine should not be given. He does not need a tetanus shot since he had it within the last 10 years.
Hypotension after intubation for severe COPD: commonest cause
Air trapping
Rx: disconnect
ICU: common situations when auto-PEEP develops
- high minute ventilation,
- expiratory flow limitation
- expiratory resistance.
Auto-PEEP increases intrathoracic pressure, which can decrease venous return, reduce cardiac output, and potentially cause hypotension. It can also cause alveolar overdistension, increasing the likelihood of pulmonary barotrauma and ventilator-associated lung injury. Finally, auto-PEEP increases the work required for a patient to trigger a ventilator breath if pressure-triggering is being used. (See ‘Potential sequelae’ above.)
Epidemiology: histoplasmosis, coccidiomycosis, paracocidiomycosis
- Coccidio: Southwest
- Histo: Ohio+Mississippi
- Paracoc: South+Central America
Histo: DDx
Sarcoid
The clinical and radiographic findings in pulmonary histoplasmosis and sarcoidosis may be similar [25]. A mistake in diagnosis can be disastrous if the patient is treated with corticosteroids or other immunosuppressive medications [3]. Although such patients may appear to improve transiently, they eventually experience progressive disseminated disease, which may result in increased morbidity and mortality if the true diagnosis is not identified. I
Mass at jaw; woody; sinus
Actinomyces israeli, penicillin
Cervicofacial actinomycosis is a chronic disease characterized by abscess formation, draining sinus tracts, fistulae, and tissue fibrosis. It can mimic a number of other conditions, particularly malignancy and granulomatous disease. (See ‘Introduction’ above.)
●Cervicofacial actinomycosis is caused by branching gram-positive bacteria with a variable cellular morphology, ranging from diphtheroidal to coccoid filaments (picture 1) belonging to the genus Actinomyces. (See ‘Microbiology’ above.)
●Actinomyces are noted for forming characteristic sulfur granules in infected tissue but not in vitro (figure 1). (See ‘Sulfur granules’ above.)
●A hallmark of cervicofacial actinomycosis is the tendency to spread without regard for anatomical barriers, including fascial planes or lymphatic drainage, and the development of multiple sinus tracts. Actinomyces species capitalize on tissue injury or mucosal breach to invade adjacent structures; dental infections and oromaxillofacial trauma are common antecedent events. (See ‘Pathogenesis’ above.)
Leprosy: DxMethod
Skin biopsy
Pyelonephritis: not improving: CT or US?
CT
CT is much more sensitive, detects smaller lesions
Candidemia: Rx
Capsofungin
For nonneutropenic and neutropenic patients with candidemia, we recommend an echinocandin rather than fluconazole or amphotericin B (table 1) (Grade 1B).
ndergo an ophthalmologic examination by
can improve yield of fastidious organisms (eg, Brucella spp and fungi) [54,55]. This culture system contains components that lyse leukocytes and erythrocytes, as well as inactivate plasma complement and certain antibiotics.
Lysis centrifugation
Endocarditis: commonest complication
• Cerebral complications are the most frequent and most severe extracardiac complications. Vegetations that are large, mobile, or in the mitral position and infective endocarditis due to Staphylococcus aureus are associated with an increased risk of
Infective focus: finding
- Echo
- CT abdomen/pelvis
- MRI spine
- Tagged WBC
- Special cultures: lysis centrifugation, for example.
Interferon-gamma release assays and tuberculin skin tests: role in the diagnosis of active disease.
None
Pleural TB: BestTest
Pleural biopsy + culture
Blood culture: large Gram+ with pseudohyphae
Candida
Enterococcus endocarditis: non-resistant org
Ampicillin + gentamicin
https://www.ncbi.nlm.nih.gov/pubmed/26373316?ssource=kplus
Enterococci are relatively resistant to the killing effects of cell wall–active agents (penicillin, ampicillin, and vancomycin) and are impermeable to aminoglycosides. Antibiotic regimens and doses for susceptible strains are outlined in the Table (table 1). (See ‘Approach to susceptible strains’ above.)
Treatment of bacteremia due to susceptible enterococci (in the absence of suspected endocarditis) consists of ampicillin. Bacteremia due to ampicillin- and vancomycin-resistant E. faecium bacteremia (in the absence of suspected endocarditis) may be treated with daptomycin (8 to 10 mg/kg/day). (See ‘Bacteremia’ above.)
●For treatment of enterococcal bacteremia with suspected endocarditis or critical illness, we recommend combination antimicrobial therapy over monotherapy (Grade 1B). Of the combination antimicrobial regimens, we suggest ampicillin plus ceftriaxone since it avoids the toxicity of aminoglycosides (Grade 2B); use of a cell wall–active agent in combination with a synergistically active aminoglycoside is also acceptable.
Viral pneumonia + conjunctivitis + military recruit: organism
Adenovirus
Elderly patient presents with an itchy recurrent skin rash:
Pruritic papulosquamous lesions in the right axilla and antecubital fossa → vesicles and bullae mostly intact
Lesions are not symmetric and do not always occur in the same place
Normal mucosal surfaces
Improvement with potent topical corticosteroid
What is the diagnosis?
ullous pemphigoid (BP).
Onset in older persons and intensely pruritic bullae that improve with topical corticosteroids. Dermatitis herpetiformis could look similar, except that it is not typically restricted to flexural areas (biopsy is needed for definitive exclusion) and is often presented in the context of celiac disease. It’s reasonable to remember the biopsy findings in the event they are included in a clinical scenario.
Dx: Skin biopsies for light microscopy (subepidermal blister with inflammatory cells in superficial infiltrate) and direct immunofluorescence shows linear deposition at the basement membrane. BP antibodies (BP180 and BP230) can be measured with ELISA with good sensitivity and specificity, but test is rarely available.
Tx: Systemic corticosteroids are 1st line treatment, although topical steroids can be used in mild disease. Immunosuppressants are often used as steroid sparing agents.
Female patient with h/o recurrent axillary nodules for years presents with:
Pain in both axillary regions x ~ 2 months—began as small “bumps” but getting larger
Significant pain and erythema around the bumps x 24 hours
Deep, nodular lesions in both axillae without any central area of necrosis
Few comedones in the axillae
What is the diagnosis?
hidradenitis suppurativa (HS).
Tx: Weight loss and smoking cessation, if applicable; breathable clothing; avoid washcloths, depilatory creams/lotions, and shaving of the region; use gentle soaps; antiperspirants are okay as long as does not irritate; antibiotics, if cellulitis present; surgical incision and drainage, when necessary; immunomodulators or systemic retinoids are used in very severe disease (corticosteroids, infliximab or adalimumab, cyclosporin, isotretinoin).
