Cutaneous Disorders

One Step Further Question: What distinguishes chickenpox from smallpox?

Answer: The crops of smallpox all develop with the same timing whereas in chickenpox they present in various stages.

One Step Further Question: What is black dot Tinea capitis?

Answer: This refers to an infection that causes the hair to fracture, leaving the infected dark stubs visible in the infected regions.

One Step Further Question: What is a first line treatment for psoriasis?

Answer: Topical corticosteroids.

One Step Further Question: Genital herpes increases the risk for acquiring what other sexually transmitted disease?

Answer: HIV infection.

One Step Further Question: What is the most common location for zoster to occur in?

Answer: Thorax, followed by the face (trigeminal nerve).

One Step Further Question: What is the treatment for herpes simplex?

Answer: Three medications can be used for treatment of herpes infections: acyclovir, valacyclovir, and famciclovir.

One Step Further Question: What layer of skin edema defines urticaria?

Answer: Urticaria involves localized dermal edema produced by transvascular fluid extravasation.

One Step Further Question: What is the most common cause of death from seafood consumption in the United States?

Answer: Vibrio vulnificus septicemia.

One Step Further Question: Is there a male or female predominance with erythema nodosum?

Answer: Yes, a female predominance exists (1:6 male to female).

One Step Further Question: Should family members of an infected individual also be treated for scabies?

Answer: Yes, family members and sexual contacts.

One Step Further Question: When are patients with herpes zoster considered to no longer be infectious?

Answer: Patients are no longer considered infectious once the herpes zoster lesions are crusted over.

One Step Further Question: What is the infectious agent that causes tinea versicolor?

Answer: Pityrosporum ovale, which was recently renamed Malassezia furfur.

One Step Further Question: What are 5 treatments for HPV warts?

Answer: Podofilox, imiquimod, cryotherapy, trichloroacetic acid, surgical removal.

One Step Further Question: What type of virus causes molluscum contagiosum?

Answer: Pox virus.

One Step Further Question: What is the characteristic finding consistent indicative of corneal ocular involvement in zoster ophthalmicus?

Answer: Pseudodendrites (no terminal bulb).

One Step Further Question: What labs should be considered in pityriasis rosea?

Answer: RPR or VDRL to rule out syphilis.

One Step Further Question: What is the name of the obligate human parasite that causes scabies?

Answer: Sarcoptes scabiei.

Which of the following skin cancers is seen above? Basal cell carcinoma Kaposi sarcoma Melanoma Squamous cell carcinoma

Correct Answer ( A ) Explanation: Basal cell carcinoma is due to a malignant transformation of epithelial cells and usually occurs in sun-exposed areas such as the forehead and nose. It is slow growing. It is often described as a small pearly nodule with telangiectatic vessels. It may develop a central ulcer with a "rolled" raised edge. Treatment is surgical excision or radiation therapy Kaposi sarcoma (B) is a multisystem vascular neoplasm characterized by mucocutaneous violaceous lesions (often mistaken for ecchymosis) usually associated with acquired immune deficiency syndromes (e.g., AIDS). These lesions can occur anywhere on the body. Melanoma (C) results from malignant transformation of melanocytes related to sun exposure. Early identification is critical because it is a fast-growing neoplasm. Cutaneous features concerning for melanoma include (1) recent change in size, shape, and color; (2) different from patient's other pigmented lesions; (3) irregular boarders; (4) irregular pigmentation with colors of red, white, or blue; (5) areas of pigment regression. Squamous cell carcinoma (D) has a greater malignant potential than basal cell has. It occurs in sun-exposed areas. It is often described as an ulcerated nodule or superficial erosion on the skin and lip. Telangiectasia is uncommon. Patients sometimes describe it as a "cut that won't heal that bleeds easily."

Which of the following is concerning for melanoma? Areas of pigment regression Other similar lesions Pearly border Regular border

Correct Answer ( A ) Explanation: Melanoma is a highly aggressive malignancy of melanocytes in the skin. Although it is the least common skin malignancy, it has the highest mortality. The peak incidence occurs in 20- to 45-year-olds which is much younger than the other two forms of skin cancer (basal cell carcinoma and squamous cell carcinoma). Any new mole after age 35 needs a dermatologic evaluation since people rarely form new moles at this age. The mnemonic ABCDE helps to remember the characteristics of melanoma: Asymmetry, Border (irregular), Color (different shades, not uniform), Diameter (>6 mm), Evolution. Areas of pigment regression describe changes in color and a lack of uniformity of the lesion. Other similar lesions (B) are atypical. Patients may have nevi or skin moles that appear similar, but as a lesion progresses to become melanoma it looks different from other moles on the body. A pearly border (C) is more consistent with a basal cell carcinoma. These lesions often begin as a pearly papule with telangiectasias. Regular borders (D) are uncommon as the malignancy does not grow in a uniform pattern.

A 9-year-old boy presents to the ED with bilateral knee pain, low-grade fever, nausea, vomiting, and diarrhea for the past 4 days. His vital signs are blood pressure of 116/80 mm Hg, heart rate of 98 beats per minute, respiratory rate of 14 breaths per minute, and a temperature of 38.1°C. On examination, you note the rash seen above. Urinalysis is positive for hematuria. Which of the following statements is the most accurate? Despite plasma exchange, most patients progress to chronic renal impairment Long-term prednisone therapy improves 5-year survival to greater than 50% The disease is self-limited; most cases resolve within 6-8 weeks Without treatment, the disease carries a mortality rate of 80% at one year

Correct Answer ( C ) Explanation: The patient has Henoch-Schönlein purpura (HSP). This small-vessel vasculitis predominantly occurs in small children. Most cases follow an upper respiratory tract infection. HSP classically presents with fever, abdominal pain, arthritis, hematuria, and a pathognomonic round, palpable, symmetrical rash that appears on the dependent areas of the legs and buttocks. NSAIDs, dapsone, and prednisone have all been shown to relieve symptoms. The course of disease is typically self-limited. Most cases resolve within 6 to 8 weeks, with a recurrence rate of up to 33%. Plasma exchange (A) has been found to be successful in the treatment of microscopic polyangiitis. In HSP, most patients do not progress to chronic renal impairment. Prednisone (B) therapy has increased the 5-year survival rate to greater than 50% in Churg-Strauss Syndrome, which is typically associated with fever, weight loss, malaise, and pulmonary symptoms, but it does not affect survival in HSP. Granulomatosis with polyangiitis (D), not HSP, once carried a 1-year mortality rate of 80%, however, the combination of cyclophosphamide and corticosteroids has been successful in inducing remission in more than 90% of patients.

A 55-year-old woman presents to the emergency room with a bright red, painful, well-demarcated rash on her face as seen above. Which of the following organisms is most likely responsible for this condition? Haemophilus influenzae Staphylococcus aureus Streptococcus pneumoniae Streptococcus pyogenes

Correct Answer ( D ) Explanation: Erysipelas is a cutaneous infection characterized by marked superficial dermal lymphatic involvement. The most common cause of erysipelas worldwide is Streptococcus pyogenes (group A beta-hemolytic Streptococcus). Facial erysipelas is frequently associated with streptococcal pharyngitis. Another common location for this infection is the lower legs. Additional risk factors include breaks in the skin barrier, venous disease, immunosuppression, and previous episodes of erysipelas or cellulitis. Clinical manifestations include raised, bright salmon-red colored lesions above the level of the surrounding skin with a clear line of demarcation between involved and uninvolved skin. Plaques may develop vesicles or bullae. In facial erysipelas, one or both eyes are frequently swollen shut. Fever, chills, headache, vomiting, and joint pain may precede the rash. Diagnosis is made by history and clinical presentation. Diagnostic tests may show an elevated white blood cell count, raised C-reactive protein, and positive blood cultures. Early diagnosis and treatment has an excellent prognosis. Empiric antibiotic therapy should be started immediately. First-line treatment is an oral penicillin such as amoxicillin. For patients with systemic symptoms, intravenous ceftriaxone or cefazolin is indicated. . Erythromycin can also be used but is associated with increasing resistance. Additional management includes analgesics, elevation of the involved area, compression stockings, and proper wound care. Complications are rare but may include abscess, thrombophlebitis, lymphatic damage, recurrent infection, infective endocarditis, septic arthritis, scarlet fever, post-streptococcal glomerulonephritis, cavernous sinus thrombosis, and toxic shock syndrome. Skin changes may take weeks to resolve but generally do not involve scarring. Haemophilus influenzae (A) is a common cause of erysipelas in children, however, it has significantly decreased in incidence due to introduction of the Hib vaccine. Staphylococcus aureus (B) is more likely to cause purulent skin infections, whereas group A beta-hemolytic Streptococci are more likely to cause non-purulent skin infections such as erysipelas, cellulitis, necrotizing fasciitis, and myonecrosis. Streptococcus pneumoniae (C) is an alpha-hemolytic streptococcal pathogen that inhabits the respiratory tract and is rarely associated with cutaneous infections.

Rapid Review Paronychia

Paronychia PE will show an infection of lateral nail fold Most commonly caused by S. aureus Treatment is ABX, warm soaks, I&D

One Step Further Question: Due to increased antibiotic resistance, what is the current recommended treatment for gonorrhea?

Answer: Dual therapy with ceftriaxone and either azithromycin or doxycycline.

One Step Further Question: What rashes commonly appear on the palms?

Answer: Erythema multiforme, drug eruption, secondary syphilis, Rocky mountain spotted fever, hand-foot-and-mouth disease, scabies.

One Step Further Question: What are criteria for admitting a patient with cellulitis on outpatient antibiotics?

Answer: Failure to improve or worsening cellulitis after 48-72 hours of appropriate therapy.

One Step Further Question: Which division of the trigeminal nerve is the ophthalmic branch?

Answer: First division (V1).

One Step Further Question: The finding of hair loss in the setting of a scalp rash suggests what diagnosis?

Answer: Fungal infection.

One Step Further Question: What finding can help distinguish between septic arthritis and Henoch-Schönlein purpura in a child who refuses to weightbear?

Answer: Henoch-Schönlein purpura often affects both lower extremities symmetrically, whereas septic arthritis is typically unilateral.

One Step Further Question: What is the most common serious side effect of treatment with oral ketoconazole?

Answer: Hepatic toxicity.

One Step Further Question: What is the treatment of choice in those who develop Erythema multiforme?

Answer: In most cases of EM, supportive treatment is all that is necessary. Oral antihistamines, steroids, and analgesics may be beneficial.

One Step Further Question: What specific gastrointestinal disorder is associated with Henoch-Schönlein purpura?

Answer: Intussusception.

One Step Further Question: What are the classic viral exanthems?

Answer: Measles (first disease), rubella (third disease), erythema infectiosum (fifth disease), and roseola infantum (sixth disease).

One Step Further Question: Is Pityriasis rosea contagious?

Answer: No.

One Step Further Question: What complication should herpes zoster lesions at the tip of the nose alert the clinician to?

Answer: Ocular herpes zoster is correlated with lesions at the tip of the nose - called Hutchinson's sign.

One Step Further Question: How soon after removal of an infected pacemaker can another permanent pacemaker be placed?

Answer: Only after 4-6 weeks of intravenous antibiotics.

One Step Further Question: What is the most common cause of impetigo?

Answer: Staph. aureus followed by group A streptococcus.

One Step Further Question: What is the most serious long-term complication of measles infection?

Answer: Subacute sclerosing panencephalitis.

One Step Further Question: What is the treatment of choice for onychomycosis?

Answer: Systemic antifungals (eg. terbinafine) are considered first line treatment. Topical agents are typically less effective.

One Step Further Question: Why is trimethoprim-sulfamethoxazole (TMP-SMX) a poor choice as a single agent to treat cellulitis?

Answer: TMP-SMX is active against most methicillin resistant Staphylococcus aureus but has poor coverage against group A streptococci; an organism often implicated in cellulitis.

One Step Further Question: What type of hypersensitivity reaction is allergic contact dermatitis?

Answer: Allergic contact dermatitis is a form of delayed hypersensitivity (type IV) reaction mediated by lymphocytes sensitized by the contact of the allergen with the skin.

One Step Further Question: What dangerous complication of parvovirus B19 infection is seen in patients with sickle cell disease?

Answer: Aplastic anemia.

One Step Further Question: What is the most common skin cancer?

Answer: Basal cell carcinoma. It is rarely fatal.

One Step Further Question: What is the most common autoimmune blistering disease in the elderly?

Answer: Bullous pemphigoid.

One Step Further Question: For what indication is oral vancomycin most useful?

Answer: C. difficile colitis.

One Step Further Question: In patients with chronic or unresponsive paronychia, what organisms are likely involved?

Answer: Candida albicans and atypical mycobacteria.

One Step Further Question: What is the only topical prescription medication available in the United States for the treatment of onychomycosis?

Answer: Ciclopirox 8% solution.

One Step Further Question: What is the prognostic indicator of a melanoma lesion?

Answer: Depth of invasion.

One Step Further Question: What is the most common complication of measles?

Answer: Diarrhea

One Step Further Question: What is the characteristic pattern seen when lesions follow the Langer's lines in Pityriasis rosea?

Answer: "Christmas tree" pattern.

One Step Further Question: What is the treatment for erysipelas?

Answer: A parenteral antistreptococcal antibiotic such as ceftriaxone or cefazolin.

One Step Further Question: What is the most serious complication of impetigo?

Answer: Acute glomerulonephritis.

Which of the following statements is true regarding the condition seen above? May lead to scarring alopecia Primarily due to bacterial infection Requires long-term topical treatment with antifungal Usually painless

Correct Answer ( A ) Explanation: The image depicts a patient with a kerion. This condition begins as Tinea capitis (scalp ringworm) that undergoes a delayed-type hypersensitivity reaction to the causative fungus. This inflammation causes the initial erythematous, scaly plaque of Tinea capitis to become boggy with inflamed purulent nodules and plaques. The hair follicle is frequently destroyed by the inflammatory process in a kerion, leading to scarring alopecia. Treatment includes long-term systemic therapy, usually with oral griseofulvin and the addition of an antibiotic to treat any secondary bacterial infection. In addition, oral corticosteroids are administered to treat the severe inflammation. Tinea capitis is a dermatophyte (B) infection most commonly caused by Trichophyton tonsurans transmitted from person to person via fomites, such as a barber's razor. Treatment with topical agents (C) is inadequate; patients require systemic therapy. The initial infection of Tinea capitis is usually painless (D) with intense pruritus at times. However, with progressive inflammation and the development of a kerion, the lesion becomes painful.

The rash seen above is associated with which of the following conditions? Acute glomerulonephritis Arthritis Clostridium difficile colitis Secondary syphilis

Correct Answer ( A ) Explanation: The image represents impetigo, a pustular eruption most commonly seen in preschool children. Acute poststreptococcal glomerulonephritis (APSGN) results from an antecedent infection of the skin or throat caused by nephritogenic strains of group A beta-hemolytic streptococci. APSGN usually occurs 10 days after pharyngitis and 14 days after skin infection. The incidence is decreasing in the United States but is still common in some rural areas. APSGN is not well understood, but it probably results from the deposition of circulating immune complexes in the kidney. This results in decreased glomerular filtration, allowing proteins to flow freely into the urine. Urinalysis shows significant blood and protein with RBC casts in 60% of cases. Pyuria with granular or hyaline casts also may be found. Impetigo is not associated with arthritis. Other skin conditions such as psoriatic arthropathy (B) occur in up to 20% of patients with psoriasis. Clostridium difficile (C) bacteria proliferate when the normal bowel flora is substantially reduced by antibiotic therapy. If the bacteria produce sufficient quantities of toxin, colitis develops. There are a number of cutaneous manifestations of secondary syphilis (D). Lesions may be erythematous or pink macules or papules, usually with a generalized symmetrical distribution.

A 33-year-old woman presents to the ED with the lesions seen above. She began taking an antibiotic for her urinary tract infection 2 days prior to noting the lesions. Which of the following is true regarding this condition? Associated with arthralgia in the majority of cases Flexor surfaces are usually involved Lesions are nontender There is a predilection for the mucous membranes

Correct Answer ( A ) Explanation: The lesions are due to erythema nodosum, an inflammatory reaction between the dermis and adjacent adipose tissue. It is thought to be a delayed hypersensitivity reaction to various infections, drugs, or a systemic disease. Sulfonamides, oral contraceptives, penicillins, and phenytoin are often implicated. The patient is likely taking sulfamethoxazole and trimethoprim for her UTI. A variety of infections and systemic disorders such as Streptococcal infections (most common infection), sarcoidosis, inflammatory bowel disease, systemic lupus erythematosus, lymphoma, and leukemia are associated with erythema nodosum. The hallmark lesions of erythema nodosum are tender erythematous subcutaneous nodules that have a blue hue as they resolve. Symmetrical pretibial involvement is most common, although the extensor surfaces of the forearm, thigh, and trunk may also be affected. Patients may have just the nodules or may have systemic symptoms, including fever and malaise. Arthralgias are seen in 90% of patients at some time during the disease course and have been known to persist for up to 2 years after resolution. The skin eruption can last up to 6 weeks. Although the lesions are exquisitely tender, erythema nodosum tends to be self-limited. Treatment is mainly supportive with the identification of the underlying disorder. NSAIDs may be useful in controlling the arthralgias. Extensor, not flexor (B), surfaces are usually involved. Lesions are tender, not nontender (C). Mucous membranes (D) are not involved as in other disorders such as Stevens-Johnson syndrome or toxic epidermal necrolysis.

Which of the following is an appropriate treatment for the painful penile lesion pictured above? Acyclovir Azithromycin and ceftriaxone Benzathine penicillin G Doxycycline

Correct Answer ( A ) Explanation: The picture depicts the characteristic ulcerative lesions seen in genital herpes, the most common cause of sexually transmitted genital ulcerations in the United States. Lesions may be grouped, fluid-filled vesicles or ulcers on an erythematous base. Herpes simplex virus 2 (HSV-2) accounts for the majority of cases of genital herpes, but it may also be caused by herpes simplex virus 1 (HSV-1). Clinically, genital herpes manifests as either a primary infection or a local recurrence from reactivation of dormant virus in the spinal cord ganglia. Primary infection tends to be more severe with systemic symptoms, more copious genital lesions, and a prolonged clinical course. The diagnosis is largely clinical, although it can be confirmed with serologic testing, viral culture, or antigen retrieval from the lesions. The Tzanck test, once the mainstay of diagnosis, is no longer widely performed due to a lower sensitivity than newer testing has. Although outbreaks are self-limited and heal spontaneously, treatment with antiviral medication may decrease the duration of symptoms, decrease the amount of viral shedding (and thus infectivity), and reduce recurrences. It is also important to provide pain relief and educate the patient about sexually transmitted diseases. Azithromycin and ceftriaxone (B) is an appropriate treatment for chlamydia and chancroid. Benzathine penicillin (C) is an appropriate treatment for primary or secondary syphilis. Latent syphilis requires 2 additional treatments, each 1 week apart. Doxycycline (D) would be appropriate treatment for chlamydia and lymphogranuloma venereum.

A 48-year-old man with a history of diabetes mellitus presents to the ED with scrotal and perineal pain, fevers, chills and fatigue. He reports the onset of his symptoms several hours ago with lower abdominal pain. On exam, he has T 39.6°C, BP 104/80, HR 112, RR 22, oxygen saturation 100% on room air. He appears ill, and there is darkened discoloration throughout his perineum and part of his scrotum with crepitus. Which of the following pairs represents the most likely causative organisms? Bacteroides fragilis, Escherichia coli Chlamydia trachomatis, Methicillin-resistant Staphylococcus aureus Staphylococcus aureus, Streptococcus pyogenes Staphylococcus epidermidis, Streptococcus viridans

Correct Answer ( A ) Explanation: This is a patient with Fournier's gangrene, a necrotizing infection of the subcutaneous tissue of the perineum. It spreads rapidly and often features discoloration of the skin along with crepitus, which is indicative of subcutaneous gas. The infection is polymicrobial. The causative organisms are mostly bacteria from the distal colon with aerobic and anaerobic bacteria. The most common are B. fragilis and E. coli. The other answer choices, (B), (C), and (D) reflect mostly Gram-positive organisms and do not feature any anaerobes. MRSA (B), S. aureus, and S. pyogenes (C) are frequent causes of cellulitis. Chlamydia infection often leads to urethritis. S. epidermidis (D) is part of human skin flora and is implicated in catheter-related infections. S. viridans is known for its association with endocarditis.

A 16-year-old man presents with a rash to the back for one week. He states that the rash started as a single patch and then spread to the rest of his back. The rash is itchy but otherwise, the patient is asymptomatic. What management is indicated? Antihistamines Cephalexin Oral corticosteroids Topical antifungals

Correct Answer ( A ) Explanation: This patient presents with pityriasis rosea and should be treated symptomatically with antihistamines as the condition is self-limiting. Pityriasis rosea presents as scaly, salmon colored, oval papules or plaques 1 - 2 cm in diameter on the trunk and proximal extremities. It usually presents in children and young adults. Classically, the diffuse rash is preceded by a herald patch 1 week prior. This lesion is larger (2-5 cm in diameter) than the others that form. Patients may also initially have fever, malaise or lymphadenopathy prior to the appearance of a rash but this is rare. The diffuse form of the rash has a Christmas tree-like distribution following the cleavage lines of the skin. Pityriasis rosea is a self-limiting disease but may take 8-12 weeks to completely resolve. The causative agent is unknown although a virus is suspected (HHV 7). There is no specific treatment for the disease and so care should be directed at relieving symptoms, most commonly itching, with antihistamines. Cephalexin (B) is a first generation cephalosporin with activity against many streptococcus and staphylococcus species, which are not implicated in pityriasis rosea. Oral corticosteroids (C) have not been shown to reduce symptoms or duration of pityriasis rosea. Although tinea infections are on the differential diagnosis for pityriasis rosea, a fungal etiology has not been shown to be causative of the disease and topical antifungals (D) do not play a role in treatment.

A 5-year-old boy presents with fever and rash for two days. Examination reveals a well-appearing child with marked erythema to both cheeks as seen above. What management is indicated? Acetaminophen for fever Cephalexin Mupirocin Topical hydrocortisone

Correct Answer ( A ) Explanation: This patient presents with symptoms consistent with erythema infectiosum and requires supportive care. Erythema infectiousum, or fifth disease is caused by infection with parvovirus B19. The disease is characterized by rash and mild systemic symptoms. The classic rash is deeply red on the face giving a "slapped-cheek" appearance with circumoral pallor. Additionally, a maculopapular, lacelike rash may be seen on the arms and progresses caudally. Rarely, parvovirus B19 has been associated with hepatitis. There is no specific treatment for erythema infectiosum and so management should focus on supportive care and parental reassurance. Acetaminophen or ibuprofen can be used to treat the fever. Cephalexin (B) is a first generation cephalosporin with activity against many streptococcus and staphylococcus species, which are not implicated in erythema infectiousum. Mupirocin (C) is used in the treatment of impetigo. Topical hydrocortisone (D) is useful in the treatment of allergic reactions but not in parvovirus B19 infections.

Which of the following is correct regarding the condition seen in the image above? Involvement of the scalp and nails is uncommon It is associated with the Auspitz sign Lesions most commonly occur on flexor surfaces Systemic steroids are the preferred treatment

Correct Answer ( B ) Explanation: The well-demarcated erythematous plaques and papules with silvery white scales are characteristic of psoriasis. Removal of the scale typically reveals pinpoint-bleeding areas referred to as the Auspitz sign. There is a hereditary predilection for the condition and often begins in the 2nd or 3rd decade of life. Lesions tend to be symmetric and most commonly found on the trunk, scalp, nails (A), and extensor surfaces (C). Systemic steroids (D) should be avoided due to the risk of developing rebound or induction of pustular psoriasis.

A 65-year-old woman presents with skin lesions seen above. When you apply lateral pressure to the bullae, they do not extend. Which of the following statements is correct regarding this condition? Bullae evolve into painful ulcers It is a chronic autoimmune disease Often seen in young individuals Oral lesions are present in a majority of cases

Correct Answer ( B ) Explanation: Bullous pemphigoid is a chronic autoimmune blistering disease often seen in patients older than 60 years of age. The blisters occur deep, within the epidermal basement membrane, which is why they do not extend with lateral pressure (Nikolsky sign negative). The Nikolsky sign is dislodgement of intact superficial epidermis by a shearing force, indicating a plane of cleavage in the skin. The defect may be due to staphylococcal toxin as in staph-scalded skin syndrome, or to epidermal antibodies as in pemphigus.The bullae evolve over weeks to months and most commonly occur in the axillae, abdomen, inner thighs, flexural forearms, and lower legs. The affected skin may be intensely pruritic. Pemphigus vulgaris (A and D) is associated with bullous lesions that often occur in the perioral region and erode to leave painful ulcers. Pemphigus vulgaris is associated with a positive Nikolsky sign. Bullous pemphigoid occurs mainly in individuals older (C) than 60 years of age. Pemphigus vulgaris occurs most commonly in younger individuals aged 40 to 60 years.

Which of the following is most suggestive of measles infection? A prodrome of fever, lymphadenopathy, and conjunctivitis followed by a maculopapular rash that starts on the face and spreads to the trunk and limbs Diffuse maculopapular rash with white spots on the buccal mucosa High fever for 3 days followed by the appearance of a pink maculopapular rash after defervescence Presence of shallow ulcers on oral mucosa and vesicular lesions on the palms and soles

Correct Answer ( B ) Explanation: Measles (rubeola) is caused by a paramyxovirus and spread by respiratory contact. Measles begins with a prodrome of fever, coryza, cough, and conjunctivitis for several days followed by the development of a morbilliform rash. The rash starts with erythematous maculopapular lesions a few millimeters in diameter which become confluent. The rash typically starts on the face and spreads to the extremities. White spots on the buccal mucosa, known as Koplik spots, are pathognomonic for measles. Complications include otitis media, pneumonia, myocarditis, pericarditis, and encephalitis. Treatment is supportive. High fever for 3 days followed by the appearance of a pink maculopapular rash after defervescence (C) is classic for roseola. Roseola infantum, also known as exanthema subitum or sixth disease, is caused by human herpes viruses (HHV) 6 and 7. Affecting primarily infants and young children, it is characterized by high fever for 3 days which defervesces abruptly with the development of a pink maculopapular rash. A generally benign, self-limited condition, treatment is supportive. Presence of shallow ulcers on the oral mucosa and vesicular lesions on the palms and soles (D) is most suggestive of hand, foot and mouth disease. Commonly caused by coxsackie virus subtypes, hand, foot, and mouth disease is a highly contagious viral infection spread by fecal-oral route, respiratory droplets and contact with skin lesions. It begins with a prodrome of low-grade fever, anorexia, and mouth pain for 1-2 days prior to the appearance of the characteristic oral vesicular lesions which may ulcerate, and palm and sole lesions. A maculopapular rash may also be present. It is most common in preschool-aged children, and incidence peaks in summer and autumn. Treatment is supportive. A prodrome of fever, conjunctivitis, and lymphadenopathy followed by a maculopapular rash that starts on the face and spreads to the trunk and limbs (A) is suggestive of rubella infection. Rubella is caused by a togavirus and spread by respiratory droplets. Rubella begins with a prodrome of fever, lymphadenopathy, and conjunctivitis for 3 days followed by the development of a facial maculopapular rash that subsequent spreads to the trunk and limbs. Treatment is supportive and complications are unusual. However, primary infection with rubella in pregnancy can lead a constellation of severe symptoms in the developing fetus, and rubella is one of the "TORCH" infections. Transplacental rubella infection can lead to congenital rubella syndrome, which can result in sensorineural deafness, cataracts, cardiac malformations, and neurologic sequelae. Purpuric skin lesions associated with congenital rubella syndrome are known as "Blueberry muffin" spots.

A 29-year old man presents with complaints of deformed and discolored toenails. On exam, you note the findings seen above. A KOH scraping from the subungual debris is positive for hyphae. Which of the following is the most appropriate first-line treatment for this patient? Oral ketoconazole 200 mg daily for 6 weeks Oral terbinafine daily for 12 weeks Oral trimethoprim/sulfamethoxazole daily for 12 weeks Topical ketoconazole daily for 6 weeks

Correct Answer ( B ) Explanation: Onychomycosis describes nail infections caused by any fungus, including dermatophytes, yeasts, and nondermatophyte molds. Onychomycosis may involve the nail plate and other parts of the nail unit including the nail matrix. The majority of distal and proximal subungual onychomycosis results from Trichophyton rubrum. Yeast onychomycosis is most common in the fingers and is most often caused by Candida albicans. The diagnosis is usually clinical but can be confirmed by KOH and culture. Clippings of the nail plate and scrapings of the subungual keratosis can be examined with KOH and microscopy. Nail clippings can also be sent to pathology in formalin to be examined with periodic acid-Schiff (PAS) stain for fungal elements. The first-line treatment is terbinafine, a synthetic antifungal that inhibits ergosterol synthesis. The most concerning side effect of terbinafine is liver failure. Therefore, patients should undergo monitoring of LFTs. A second-line agent is itraconazole. Oral ketoconazole (A) is used for fungal infections such as blastomycosis, cocciodiomycosis, and histoplasmosis. Although some clinicians use it for onychomycosis, it is not FDA approved. Trimethoprim/sulfamethoxazole (C) is used for treatment of bacterial infections, as well as fungal infections that include Pneumocystis jiroveci and Toxoplasmosis. Topical ketoconazole (D) is used for cutaneous fungal infections, which include: cutaneous candidiasis, Seborrheic dermatitis and Tinea infections. There is very little treatment success with any topical agent due to the poor penetration through the nail plate.

A 18-year-old woman presents with a diffuse papulosquamous rash. The rash began one month prior when she noticed a large patch on her neck that was followed by the diffuse papulosquamous rash. You inform the patient that the rash will last 5-8 weeks and prescribe her cetirizine. Which of the following is the most likely diagnosis? Contact dermatitis Pityriasis rosea Scabies Tinea versicolor

Correct Answer ( B ) Explanation: Pityriasis rosea is a common acute eruption usually affecting children and young adults; the cause is unknown. It is characterized by the formation of an initial herald patch, followed by the development of a diffuse papulosquamous rash. Pityriasis rosea is difficult to identify until the appearance of characteristic, smaller, secondary lesions that follow Langer's lines. The rash of pityriasis rosea typically lasts 8 to 12 weeks, with complete resolution in most patients. An important goal of treatment is to control pruritus, which may be severe; zinc oxide, calamine lotion, topical steroids, and oral antihistamines are usually helpful. Systemic steroids are generally not recommended. Patients should be reassured about the self-limited nature of pityriasis rosea. Persistence of the rash or pruritus beyond 12 weeks should prompt reconsideration of the original diagnosis, consideration of biopsy to confirm the diagnosis, and questioning the patient again about use of medications that may cause a rash similar to that of pityriasis rosea. Findings of contact dermatitis (A) can include erythema, vesicles, bullae, exudation, and crusting from breaking of blisters, swelling, and scaling. Taking a careful history and patch testing are often the key to diagnosis. In scabies (C) patients present with a pruritic rash that is often worse at night. Skin findings include papules, nodules, burrows, and vesiculopustules. The distribution includes the interdigital spaces, wrists, ankles, waist, groin, and axillae. Pruritic nodules around the axillae, umbilicus, or on the penis and scrotum are highly suggestive of scabies. Tinea versicolor (D) presents with hypopigmented, pink/brown macules and patches on the trunk with fine scale. Versicolor means varied colors, and this tinea tends to be white, pink, and brown. Tinea versicolor is found on the back, chest, abdomen, and upper arms, often in a cape-like distribution.

A 22-year-old man presents to the ED with the rash seen above. He first noticed a lesion form about one week ago and since then noticed more smaller lesions appear all over his back and chest. He states the rash is mildly pruritic but otherwise feels fine. On exam, you note multiple 1- to 2-cm pigmented oval plaques that are 1 to 2 cm in diameter. The patient is curious about your diagnosis. What do you tell him? No treatment is required; this rash will resolve in 5-7 days No treatment is required; this rash will resolve in 8-12 weeks The rash will resolve with oral medication in 5-7 days The rash will resolve with topical medication in 1-2 weeks

Correct Answer ( B ) Explanation: Pityriasis rosea is a mild skin eruption predominantly found in children and young adults. In 50% of cases, the generalized eruption is preceded one week prior by the appearance of a "herald patch." This is a larger lesion that resembles the smaller lesions. The smaller lesions subsequently appear in a Christmas tree-like distribution and form parallel to the ribs. The lesions are sometimes pruritic and rarely occur in the oral cavity. Pityriasis rosea is self-limited, resolving in 8 to 12 weeks. While no specific treatment is required, diphenhydramine or hydroxyzine can be prescribed for relief of pruritus. As noted, lesions may be present for up to three months (A, C, and D).

A 75-year-old woman with a history of sick sinus syndrome status post pacemaker implantation two weeks ago presents with pain over the pacemaker site and fever. Examination reveals erythema, warmth, fluctuance and tenderness over the pacemaker site. What management should be pursued? Incision and drainage of the site Intravenous antibiotics, cardiology consultation and admission Needle aspiration of the site Oral antibiotics and follow up with cardiology

Correct Answer ( B ) Explanation: The patient presents with a subcutaneous pacemaker "pocket" infection, which requires intravenous antibiotics, specialist consultation and admission. As with all surgical procedures, pacemaker implantation carries a risk for infection. This risk is small; about 2% for local wound infection and 1% risk for bacteremia or sepsis. Unfortunately, bacteremia is unlikely to respond to conservative management with antibiotics alone and replacement is often necessary. When either local infection or bacteremia is suspected, blood cultures should be obtained and intravenous antibiotics should be initiated. Staphylococcus aureus and Staphylococcus epidermidis are the most commonly isolated bacteria (60-70%). Thus, empirical antibiotics should include vancomycin. It is difficult to distinguish local infection from systemic infection and 20-25% of those with local infections will have positive blood cultures. Although it is tempting to attempt local incision and drainage (A) of a likely abscess, this approach is contraindicated as the scalpel may inadvertently sever the pacemaker leads. Oral antibiotics (D) may be adequate for the management of a mild cellulitis but it is difficult to distinguish cellulitis from a pocket infection. Additionally, the presence of fever and fluctuance suggests a more advanced infection. A hematoma at the pacemaker site can mimic a pocket infection and needle aspiration (C) can differentiate these two processes. However, needle aspiration should only be performed under fluoroscopy because the needle may cut insulation surrounding the pulse generator or pacemaker leads leading to malfunction of the device.

A 45-year-old woman presents to the ED with the rash seen above. Which of the following is true regarding this condition? Always appears in a dermatomal distribution Firm stroking of the skin produces a wheal Mucous membrane involvement is commonly seen The rash is a mild form of Stevens-Johnson syndrome

Correct Answer ( B ) Explanation: This is an urticarial rash (hives). Urticaria may occur from a variety of agents, including foods (lobster, strawberry); drugs (penicillin, aspirin); infections (hepatitis, mononucleosis, coxsackie); change of temperature; and connective tissue disorders, to name a few. It can occur in isolation or as part of a systemic anaphylactic reaction. The characteristic rash appears as edematous plaques with pale centers and red borders. The rash of urticaria is transient, lasting less than 24 hours, though new lesions may continuously develop. Dermatographism is universally present and results in development of an urticarial wheal within 30 minutes of firm skin stroking. Herpes zoster (shingles) (A) always occurs in a dermatomal distribution and is characterized by a vesicular rash on an erythematous base. Mucous membrane involvement is pathognomonic of Stevens-Johnson syndrome (C and D) and may also be seen with anaphylaxis but is not typically seen with cases of simple urticaria.

A 44-year-old woman presents with pain to her second digit for 2 days. Physical examination reveals a small fluctuant area at the eponychium. What management is indicated? Acyclovir x 7 days Incision and drainage Oral antibiotics and warm soaks X-ray of the finger

Correct Answer ( B ) Explanation: This patient presents with a paronychia or a localized abscess of the nail fold that should be incised and drained. Patients will present with swelling and tenderness of the soft tissue at the lateral nail fold. Staphylococcus aureus is the most common causative agent in adults but in children, anaerobes may be more present (secondary to finger sucking). Management is with incision and drainage. The finger should be soaked in warm water and the edge of the skin at the nail should be gently lifted away from the nail using a scalpel blade. Subsequently, the cavity should be irrigated and packing gauze should be placed under the eponychium for 24 hours. If this were a herpetic whitlow, acyclovir (A) would be appropriate. Incision and drainage should be avoided for a herpetic whitlow as this can spread the infection. Oral antibiotics and warm soaks (C) are helpful if only cellulitis is present without abscess. X-ray of the finger (D) will not be helpful in the diagnosis or workup of a paronychia.

Which of the following describes a skin patch? AEvanescent, raised, round, or flat-topped lesion caused by edema BFirm lesion arising in subcutaneous tissue >2 cm in diameter CFlat, nonpalpable circumscribed lesion >5 mm in diameter DFlat, nonpalpable, circumscribed lesion <5 mm in diameter

Correct Answer ( C ) Explanation: A patch is defined as a flat, nonpalpable circumscribed lesion >5 mm in diameter. These lesions are seen in conditions such as tinea versicolor. A wheal (A) is described as an evanescent, raised, round, or flat-topped lesion caused by edema, such as seen in urticaria. A tumor (B) is described as a firm lesion arising in subcutaneous tissue >2 cm in diameter. A macule (D) is a flat, nonpalpable, circumscribed lesion similar to a patch, but is <5 mm in diameter.

What key clinical finding differentiates erysipelas from cellulitis? Induration Peau d'orange appearance Sharp demarcation from uninvolved skin Systemic symptoms

Correct Answer ( C ) Explanation: Erysipelas is a superficial skin infection involving the upper dermis with prominent lymphatic involvement. Beta-hemolytic streptococci usually cause it. Erysipelas is characterized by an erythematous area of skin that becomes indurated with raised borders distinctly demarcated from the surrounding normal skin. The skin may also exhibit a "peau d'orange" appearance. A classical manifestation is malar involvement with a "butterfly" pattern over the face. Because erysipelas involves the upper dermis and superficial lymphatics, whereas cellulitis involves the deeper dermis and subcutaneous fat, erysipelas can spread to pinna of the ear, whereas cellulitis cannot. Both erysipelas and cellulitis can exhibit induration (A), a "peau d'orange" appearance (B), and systemic symptoms (D).

Which of the following rashes is seen in the above image? Erythema marginatum Erythema migrans Erythema multiforme Erythema nodosum

Correct Answer ( C ) Explanation: Erythema multiforme is an erythematous, papular rash that appears within 72 hours of the inciting cause. Although the feet, face and lower extremities may be involved, the hands and forearms are most commonly affected. Papules typically evolve into target lesions with a characteristic central dusky or purple zone surrounded by a pale ring and then a 3rd erythematous halo. Discrete oral lesions may be seen in approximately 50% of patients. Erythema multiforme is a type of hypersensitivity reaction in response to medications, infections, collagen vascular disorders, and malignancies. Common medications associated with erythema multiforme include sulfonamides, penicillins, barbiturates, and phenytoin. Common infections include herpes simplex and mycoplasma infections. The exact cause is unknown. The disorder is believed to involve damage to blood vessels of the skin with subsequent damage to dermal and epidermal tissues. Approximately 90% of erythema multiforme cases are associated with herpes simplex or Mycoplasma infections. The disorder occurs primarily in children and young adults. Erythema marginatum (A) is a migratory annular and polycyclic erythematous eruption and a cutaneous manifestation of acute rheumatic fever. Erythema migrans (B) is an expanding red lesion with central clearing at the site of a tick bite and is associated with Lyme disease. Erythema nodosum (D) are tender, raised red nodules on the legs and is associated with many etiologies.

A 34-year-old man presents with a purulent skin infection. Which of the following oral antibiotics will cover community-acquired methicillin-resistant Staphylococcus aureus (MRSA)? Amoxicillin Cephalexin Doxycycline Vancomycin

Correct Answer ( C ) Explanation: Methicillin-resistant Staphylococcus aureus (MRSA) is a strain of staphylococcus that has developed resistance to beta-lactam antibiotics. This resistant strain is often healthcare-associated, but is also found in the community. For limited community-acquired infections not requiring hospitalization, patients may be treated with oral antibiotics. A tetracycline (such as doxycycline) is an acceptable choice to treat community-acquired MRSA. Clindamycin or a sulfa drug (such as TMP-SMX) is another acceptable alternative. Healthcare-associated strains of MRSA are typically not susceptible to these oral antibiotics and will require IV vancomycin. Vancomycin is a bactericidal drug that inhibits cell-wall biosynthesis. Amoxicillin (A), an aminopenicillin beta-lactam antibiotic, and cephalexin (B), a cephalosporin beta-lactam antibiotic, are both resistant against MRSA. Vancomycin (D) has good activity against MRSA and is the IV antibiotic of choice for MRSA infection, but the PO form has very little GI absorption and is not helpful for MRSA treatment as an outpatient.

What is the most common sexually transmitted infection in the United States? Chlamydia Gonorrhea Human papillomavirus Syphilis

Correct Answer ( C ) Explanation: More than 50% of sexually active individuals will contract human papillomavirus (HPV) at some point in their lives. There are over 100 types of HPV, many of which are asymptomatic and unrecognized. Two high-risk types of the virus, HPV 16 and 18, are known to cause cervical and anogenital cancers in men and women. HPV 6 and 11 are low-risk types that cause genital warts. Two HPV vaccines are available and are recommended for both men and women aged 11-12 years old. HPV2, Cervarix® for women only and HPV4, Gardasil® for both men and women. The vaccinations can also be given to individuals ages 9 - 45 years who were not vaccinated earlier. Of all diseases that are reportable to the Centers for Disease Control, chlamydia (A) is the most common and gonorrhea (B) is the second most common. However, HPV is the overall most common sexually transmitted disease. Both chlamydia and gonorrhea are major causes of pelvic inflammatory disease in women. Syphilis (D) rates are lower than those of chlamydia, gonorrhea and HPV, but have been increasing since 2000. Syphilis infection is considered to be a major health problem among men who have sex with men and there is a high rate of co-infection with HIV in this population.

Which of the following diseases presents with small grouped vesicles on an erythematous base? Aphthous ulcer Dyshidrotic eczema Herpes simplex Impetigo

Correct Answer ( C ) Explanation: The herpes simplex viruses comprise 2 distinct types of DNA viruses: herpes simplex virus (HSV)-1 and HSV-2. HSV-1 causes oral lesions in approximately 80% of cases and genital lesions in 20% of cases. The reverse is true for HSV-2, which causes genital lesions in 80% of cases and oral lesions in 20% of cases. Herpetic lesions are classically described as small grouped vesicles on an erythematous base (dew drop on a rose petal). Aphthous ulcer (A) is a common noncontagious mouth ulcer also referred to as a canker sore. The cause is not completely understood but may involve a T cell-mediated immune response triggered by a variety of factors. These are ulcers and do not contain vesicles. Dyshidrotic eczema (B) is a vesicular rash typically found on the palms, soles, and sides of fingers that presents in the 3rd decade of life with lifelong occurrences. Although it has the similar vesicular appearance as herpes, the lesions of dyshidrotic eczema are opaque and deep-seated; they are either flush with the skin or slightly elevated and do not break easily. Eventually, small blisters come together and form large blisters and generally do not occur on an erythematous base. Impetigo (D) is characterized by honey-colored crusting lesions caused by staphylococci or streptococci most commonly on the face or other exposed areas.

Which of the following is the most appropriate treatment for the rash seen above? Acyclovir Intramuscular benzathine penicillin G No treatment is necessary; lesions will spontaneously resolve Topical podofilox

Correct Answer ( C ) Explanation: The lesions pictured in the question are due to molluscum contagiosum, a common viral infection in children, sexually active adults, and immunosuppressed individuals. The lesions are best described as skin-colored pearly umbilicated papules that can be isolated as a single lesion or appear as multiple scattered papules or nodules and plaques. In children, the lesions may occur as a few or greater than 100. The lesions typically resolve spontaneously in healthy individuals. Dermatologists use some topical agents to hasten resolution. Patients should be instructed to avoid direct skin-to-skin contact to avoid spread of the virus to other individuals. Acyclovir (A) is the treatment for herpes simplex virus, which manifests as small thin-walled group vesicles on an erythematous base. Condylomata lata are papular lesions located on the folds of moist intertriginous areas that coalesce to form flat wart-like lesions, especially around the genitalia and anus. These broad, moist, highly infectious plaques develop at sites to which Treponema pallidum has disseminated in secondary syphilis. Treatment is with Intramuscular benzathine penicillin G (B). Topical podofilox (D) is mainly used in the treatment of condyloma accuminata, or genital warts; however, it can be used in treatment of molluscum if treatment is requested by the patient.

Which of the following is the most likely etiologic agent of the rash pictured above? Coxsackievirus Group A Human herpes virus 6 Parvovirus B19 Rubella virus

Correct Answer ( C ) Explanation: The most commonly recognized manifestation of parvovirus B19 infection is erythema infectiosum, also known as fifth disease. This is a benign, self-limited childhood exanthem. After a two-week incubation period, patients often develop very mild URI-type symptoms followed in three to four days by the classic "slapped-cheek" rash that appears suddenly. It is believed that the development of the rash corresponds to the onset of immune response and sudden production of anti-B19 antibodies. Parvovirus B19 has also been associated with the development of severe disease, including a symmetric polyarthropathy, myocarditis, and pericarditis. Prior theories also connected Parvovirus B19 to kidney disease, specifically focal segmental glomerulonephritis; however, this has recently been found to be coincidence rather than correlation or cause. Primary infection in patients with sickle cell disease may lead to an aplastic crisis due to disruption of hematopoiesis. Nonimmune women who become infected during pregnancy are at risk of congenital infection that may lead to hydrops fetalis and fetal loss. Coxsackievirus Group A (A) is the etiologic agent associated with hand, foot, and mouth disease and causes painful blisters on the palms, soles, and posterior oropharynx. Human herpesvirus 6 (B) is one of the etiologic agents associated with roseola infantum (roseola), characterized by a nonpruritic erythematous rash that starts on the trunk and spreads to the arms and legs and is preceded by a high fever. Rubella virus (D) is the etiologic agent associated with rubella, also known as German measles, which is characterized by a light pink, lacy, pruritic rash that starts on the face, spreads rapidly to the trunk, and fades after three days.

A 35-year-old man presents to the ED with a severe rash. A localized portion is seen in the image above. He states that he was cleaning away some brush from the woods behind his house a couple of days ago while only wearing shorts. On exam, you note similar lesions on his face, back, legs, arms, and chest. Which of the following is the most appropriate treatment? Cephalexin for 7 days Diphenhydramine as needed Prednisone taper over 21 days Prednisone taper over 7 days

Correct Answer ( C ) Explanation: The patient was exposed to poison ivy and developed allergic contact dermatitis. Contact dermatitis is an inflammatory reaction of the skin to a chemical, physical, or biologic agent. The inducing agent acts as an irritant or allergic sensitizer. Clothing, jewelry, soaps, cosmetics, plants, and medications contain allergens that commonly cause allergic contact dermatitis. The most common allergens include rubber compounds, plants of the Toxicodendron genus (poison ivy, poison oak, sumac), nickel (often found in jewelry), paraphenylenediamine (an ingredient in hair dyes and industrial chemicals), and ethylenediamine (a stabilizer in topical medications). Clinical presentation is variable with primary lesions being papules, vesicles, or bullae on an erythematous base. The distribution of the eruption depends on the specific allergen and may be localized, asymmetric linear, or unilateral. The classic lesion of poison ivy is a linear eruption that occurs from the person brushing against the poison ivy leaf. The rash usually appears 2-21 days after exposure and is associated with intense pruritus. Treatment for mild cases of contact dermatitis from poison ivy includes calamine lotion or a topical steroid and oral antihistamine. However, in moderate to severe cases, systemic steroids are indicated and should be continued for 2-3 weeks, with a gradual taper to prevent rebound of the disease. Systemic antihistamines can be taken concomitantly to help control the pruritus. Cephalexin (A) is a first-generation cephalosporin commonly used in the treatment of cellulitis. It is not used as a primary treatment in contact dermatitis but may be necessary if a secondary bacterial infection develops. Diphenhydramine (B), an antihistamine, is used as adjunctive therapy in severe cases and primary therapy for mild cases of allergic contact dermatitis. Prednisone (D) should be administered over 2-3 weeks rather than 7 days to avoid rebound of the disease. A 7-day course may treat the lesions temporarily, but often the rash returns.

A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from summer camp one week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae surrounding scattered, erythematous papules. Which of the following is the most appropriate treatment? Ketoconazole Lindane Permethrin Prednisone

Correct Answer ( C ) Explanation: This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be considered in patients with generalized pruritus, especially when exposure to others with similar symptoms is reported. The rash of scabies involves papules, which are often excoriated. Burrows are pathognomonic but not uniformly present. Unless previously infected, pruritus generally takes three to six weeks to develop because symptoms are due to delayed (Type IV) sensitivity reaction. The pruritus is classically worse at night and affects the web spaces of the fingers, flexor aspect of the wrists, axillae, groin, nipples, and the periumbilical region. Except in cases involving an immunocompromised host, the scalp and face are generally spared. Diagnosis is clinical but can be confirmed by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic examination. The treatment of choice for primary scabies infection is the application of topical scabicidal agents, with repeat application in seven days. The treatment of choice is permethrin 5% lotion. Individuals affected by scabies should avoid skin-to-skin contact with others. Patients with typical scabies may return to school or work 24 hours after the first treatment. Topical ketoconazole (A) is an antifungal agent used to treat topical dermatophytes (e.g., Tinea) and is ineffective against scabies. Lindane (B) was once a common treatment for scabies but is associated with significant potential for toxic manifestations, especially seizures. Because of this, it is no longer used to treat scabies. Prednisone (D) can be used as adjunctive therapy to reduce associated pruritus but will not eradicate the condition.

A 17-year-old man with asthma presents with an itchy, scaly rash on his arms and legs. He states that he has had the rash on and off for years. He states that the itching is severe and keeps him up at night. Physical examination reveals hyperpigmented areas to the antecubital and popliteal fossae which are thick and leathery. What management is indicated? Antibiotic ointment Cephalexin Corticosteroid ointment Oral steroids

Correct Answer ( C ) Explanation: This patient presents with an exacerbation of atopic dermatitis (AD) requiring topical corticosteroid treatment. AD is a common dermatologic condition. It is often referred to as eczema or chronic dermatitis. Patients with AD have abnormal humoral and cell-mediated immunity but the exact mechanism of the disease is unknown. AD has no pathognomonic skin lesions but does have a set of diagnostic criteria. These criteria include a history of involvement of flexor surfaces, generalized dry skin, history of asthma or hay fever, onset of rash before 2 years of age and flexor surface dermatitis. The presence of three or more of these is 85% sensitive and 96% specific for AD. AD is a chronic disease that waxes and wanes and is often worse in the winter. In general, treatment for AD is directed at controlling inflammation, dryness and itching. When patients present with acute symptoms, topical corticosteroid ointments can provide symptomatic relief. Antihistamines may be necessary as well. in addition, avoid scented products, wear light weight clothing, avoid hot baths, wash clothing in dye-free, unscented detergent. Antibiotic ointments (A) are not useful as bacteria are not the causative agent. The same is applicable to using cephalexin (B), a first generation cephalosporin. Oral steroids (D) are rarely used in the treatment of AD as topical agents are adequate.

A 17-year-old girl presents with the above rash a week after hiking in the woods. She does not report a tick bite. She otherwise has no symptoms. What management is indicated? Ceftriaxone 2 grams for 14 days Chloramphenicol 1 gram for 21 days Doxycycline 100 mg twice a day for three weeks No treatment while awaiting diagnostic testing

Correct Answer ( C ) Explanation: This patient presents with erythema migrans, the typical rash seen in early Lyme disease and requires 3 weeks of treatment with oral doxycycline. Lyme disease is an illness caused by transmission of Borrelia burgdorferi bacteria from a tick. The common vector is Ixodes scapularis. Transmission from tick to person requires attachment and feeding for more than 48 hours. Thus, early removal of ticks can prevent transmission. Typically, erythema migrans presents 7 to 10 days after infection and is proceeded by a non-specific constitutional symptoms (fever, malaise, fatigue etc.). Approximately 90% of patients report the presence of the rash. The rash begins as a small papule at the site of infection and gradually expands (1-2 cm/day). Typically, the rash will have central clearing but this is not universal. Further hematogenous spread of B. burgdorferi can cause numerous symptoms including arthralgias, neurologic manifestations, heart block etc. The diagnosis of Lyme disease is based primarily on clinical features but serologic or ELISA testing can be used to confirm the diagnosis. Prompt treatment of early manifestations can both shorten symptom duration and prevent progression to later disease stages. Early Lyme disease should be treated with oral doxycycline 100 mg twice a day for 21 days. Amoxicillin and cefuroxime are alternatives to doxycycline. You should also make sure that you obtain a negative pregnancy test in all females of child bearing age before starting on doxycycline. Ceftriaxone (A) is a third generation cephalosporin that should be used in patients with Lyme meningitis, moderate to severe cardiac manifestations or arthritis. Chloramphenicol (B) is an alternative to ceftriaxone in the treatment of Lyme meningitis. Withholding treatment while waiting for diagnostic testing (D) is not recommended because the diagnosis should be made clinically and both serologic and ELISA tests suffer from less than perfect sensitivity and specificity.

A 65-year-old man with hypertension and diabetes presents with chest pain for 2 days. He states the pain is sharp, burning and severe. You note the findings on the image above. What management is indicated? Admission for serial troponins Intravenous acyclovir for 7 days Oral acyclovir for 7 days Prednisone for 5 days

Correct Answer ( C ) Explanation: This patient presents with herpes zoster more commonly referred to as shingles. Zoster results from reactivation of latent varicella-zoster virus (VZV) in cranial nerve or dorsal-root ganglia with spread along the sensory nerve to the dermatome. The major risk factor for herpes zoster is increasing age as there is a decline in T-cell immunity. Although herpes zoster can progress to a systemic infection, particularly in those with immunocompromised states, the major complication is postherpetic neuralgia. Postherpetic neuralgia can be severe and debilitating. Antiviral therapy (usually with acyclovir or valacyclovir) is recommended in all immunocompromised patients and selected groups of nonimmunocompromised patients. Antiviral agents hasten the resolution of lesions, reduce the formation of new lesions, reduce viral shedding and decrease the severity of acute pain. Therapy should be started as soon as possible and efficacy decreases after 72 hours of symptoms. This patient's chest pain does not appear to be cardiac in origin and serial troponins (A) are not indicated. The use of glucocortocoids (D) for the treatment of herpes zoster remains controversial. Some studies have shown a reduction in acute pain and accelerated early healing. Because they are immunosuppressive, steroids should never be given alone but only in conjunction with antiviral therapy. Additionally, they should be avoided in patients with hypertension, diabetes mellitus, peptic ulcer disease and in the elderly all of whom are at increased risk of adverse events. Intravenous antivirals (B) should be considered in patients with refractory disease, multiple dermatomes (especially if they cross the midline), ocular involvement, systemic symptoms and in immunocompromised individuals.

An 8-year-old boy presents with fever for three days. He had a fever, cough and nasal congestion two days ago and this morning began with a rash. Examination reveals maculopapular, red lesions over the face, neck and chest. You also note conjunctivitis. He is otherwise well-appearing. What management is indicated? Ceftriaxone Isolation of patient from family Supportive care Tetracycline

Correct Answer ( C ) Explanation: This patient presents with symptoms consistent with measles requiring supportive care. Measles is a highly contagious viral illness spread by infectious droplets. The incubation period for the virus is 10-14 days and patients are contagious two days prior to the onset of symptoms to four days after the rash appears. The rash is typically preceded by fever, which increases daily for 5-6 days, and malaise. Cough, coryza and conjunctivitis begin about 24 hours after the onset of fever. Koplik's spots, a pathognomonic finding, appear on the second day of illness. They are small, bright red spots with blue-white centers appearing on the buccal mucosa. Rash follows on the fourth to fifth day of the illness. The rash is characterized by maculopapular lesions beginning on the forehead and face and spreading to the trunk, arms and legs. Treatment for measles focuses on supportive care and recognition of bacterial complications. Isolation of infected patients is usually not helpful as exposure usually occurs prior to identification of the disease. Additionally, patients are not contagious after the rash has been present for 5 days. Administration of human immune serum globulin (ISG) can modify the course of disease if given within 6 days of exposure. Live measles virus vaccine may prevent measles if given within 72 hours of exposure.

A 27-year-old man presents with a rash associated with mild pruritus. The rash is seen above. What treatment is indicated? Bacitracin Cephalexin Clotrimazole cream Oral ketoconazole

Correct Answer ( C ) Explanation: This patient presents with tinea corporis (ring worm), which responds to treatment with a topical antifungal agent. Tinea corporis is commonly caused by Trichophyton rubrum. Transmission occurs by person-to-person contact. The typical rash is a sharply marginated, annular lesion with raised edges and central clearing. The edges may be vesicular as well. Patients may present with single or multiple lesions affecting the arms, legs and trunk. Tinea cruris is the name applied to infections in the groin. Diagnosis is made on clinical presentation but can be confirmed by performing a KOH preparation of scrapings of the lesion. Infections usually respond to topical antifungal agents alone including clotrimazole, haloprogin, tolnaftate and miconazole. Treatment consists of two to three daily applications for 2 to 3 weeks. Bacitracin (A) is a topical antibiotic typically used to prevent infections after abrasions or lacerations. Cephalexin (B) is a first generation cephalosporin with activity against many strains of streptococcus and staphylococcus that cause cellulitis. Neither of these agents has any antifungal activity. Oral ketoconazole (D) is a potent oral antifungal agent, which can be used in more diffuse or systemic fungal infections. Ketoconazole may be used for refractory cases of tinea corporis.

An 11-year-old girl presents to the ED with the pruritic rash seen above. Upon examination of the lesions, you note they are sharply marginated with raised margins and central clearing. Scale sits at the leading edge of the erythema. Which of the following is the most likely diagnosis? Erythema migrans Erythema multiforme Tinea corporis Tinea versicolor

Correct Answer ( C ) Explanation: Tinea corporis, also known as ringworm, is a dermatophytosis, or superficial, fungal infection of the outer keratin layer of the skin. It affects the arms, legs, and trunk. It is classically a sharply marginated, annular lesion with raised or vesicular margins with central clearing. The scale is usually located at the leading edge of erythema. Lesions may be single or multiple. Skin scrapings viewed with KOH preparation exhibit septate hyphae. Treatment involves topical antifungal agents. Erythema migrans (A) is the pathognomonic rash of Lyme disease that occurs early in infection. It is described as a red plaque with central clearing. It is not as sharply marginated as tinea corporis is and lacks the scaling often seen with tinea. Erythema multiforme (B) begins with symmetric, erythematous, sharply defined macules on the extremities and trunk. The macules evolve into targetoid lesions that are flat and dusky with a central purpuric area surrounded by a raised edematous ring and peripheral erythema. Tinea versicolor (D), also known as pityriasis versicolor, is a chronic superficial fungal infection characterized by finely scaling, sharply demarcated brown macules.

A 66-year-old woman presents with a rash to the right side of her forehead that began 2 days ago. She describes it as painful, blistering, and weeping. On exam, you note the rash seen above. Which of the following is the most likely diagnosis Acne rosacea Contact dermatitis Herpes zoster Impetigo

Correct Answer ( C ) Explanation: Zoster ophthalmicus is due to reactivation of latent varicella virus in the dorsal root ganglia. It is characterized by a painful rash described as papulovesicular eruptions on an erythematous base along a dermatome. The lesions are often preceded by pain in a dermatomal distribution 2-3 days before the characteristic rash appears. Lesions often involve the face, mouth, eyes, ears, or tongue when branches of the trigeminal nerve are affected. Involvement of the tip of the nose is referred to as Hutchinson's sign and often signals concurrent ocular involvement of the nasociliary branch. Ramsey-Hunt Syndrome refers to involvement of the external auditory canal and development of an ipsilateral facial palsy. Treatment of zoster ophthalmicus involves analgesics, anti-inflammatories, and anti-viral medications (acyclovir or valacyclovir). The most common complication secondary to herpes zoster is post-herpetic neuralgia (chronic pain) of in the area of the involved dermatome. Acne rosacea (A) is an inflammatory disorder characterized by erythema, telangiectasias, and pustules primarily affecting the central face. It is primarily seen in women over the age of 30, but can be seen in men also. Contact dermatitis (B) is a rash caused by an exposure to either an irritant or allergen. The rash can be either chronic or acute and can have many different appearances depending on the type and length of exposure. Impetigo (D) is a superficial infection of the skin caused by S. aureus or beta-hemolytic streptococci. It is characterized by honey-colored, crusted lesions

Which of the following is the most common infection associated with erythema multiforme? Borrelia burgdorferi Haemophilus influenzae Type b Hepatitis C virus Herpes simplex virus

Correct Answer ( D ) Explanation: Although numerous infections have been reported in association with erythema multiforme (EM), herpes simplex virus (HSV) is the most common and best documented. Recurrent EM also is associated with infection with HSV. Demonstration of prior exposure to HSV by serology and documentation of a cutaneous recurrence of HSV infection was noted in a series of patients with recurrent EM and was less common in patients with a single episode. The pathogenesis of EM is incompletely understood, but evidence increasingly implicates a host-specific, cell-mediated immune response to an antigenic stimulus that targets keratinocytes at the dermal-epidermal junction. EM has variable cutaneous manifestations. EM is characterized by the acute onset of a symmetric, fixed cutaneous eruption of erythematous macules, papules, vesicles, or bullae most commonly distributed on the palms, dorsal surfaces of the hands and feet, and extensor surfaces of the arms and legs with relative sparing of the face, trunk and mucous membranes. Lesions can expand and evolve over several days to assume the classic annular "target" appearance with a dusky, necrotic center surrounded by a ring of edema and pallor and an erythematous border. Borrelia burgdorferi (A) is associated with Lyme's disease and skin condition called erythema migrans. Haemophilus influenzae Type b (B) is the etiologic agent in a variety of infections although less common with the advent of the pediatric Hib vaccine but can still be a causative agent of epiglottitis. It is typically not associated with erythema multiforme. Hepatitis C virus (C) is not a common cause of erythema multiforme although rash can be associated with the treatment of hepatitis C with telaprevir.

Which of the following is the first line treatment for scabies? Clotrimazole cream Lindane cream Mebendazole Permethrin cream

Correct Answer ( D ) Explanation: Permethrin cream is the treatment of choice for scabies and is applied from the neck down (include the head when involved) and rinsed off 8 to 14 hours later. Usually this is performed overnight. Scabies is caused by an obligate human parasite. Patients present with a pruritic rash that is often worse in the night. Skin findings include papules, nodules, burrows, and vesicular pustules. The distribution includes the interdigital spaces, wrists, ankles, waist, groin, and axillae. Pruritic nodules around the axillae, umbilicus, or on the penis and scrotum are highly suggestive of scabies. In children the head can also be involved. Look for burrows because these are pathognomonic of scabies and will be the best site to find mites. Scabies is a clinical diagnosis based on the typical rash and history. Lindane (B) was once used as a treatment for scabies but is now banned due to its side effect profile and its increased likelihood to cause seizure. Clotrimazole (A) is an antifungal used for all types of tinea infections of the skin. Mebendazole (C) is used in the treatment of pinworms. None of these 3 options are used in the treatment of scabies.

Which of the following is true regarding the condition seen in the image above? It is associated with a painless ulcer It is associated with an inguinal mass that forms from coalesced lymph nodes Penicillin is an effective treatment for the underlying condition The viral strains associated with this condition are the least likely to have neoplastic potential

Correct Answer ( D ) Explanation: The patient above has condylomata acuminatum, the epidermal manifestation by the human papillomavirus (HPV). More than 100 strains of the virus are directly related to an increased neoplastic risk. However, condylomata acuminata are related to HPV types 6 and 11, the least likely to have neoplastic potential. HPV infection is considered the most common sexually transmitted disease with a prevalence that exceeds 50%. HPV infection is more common in patients with immune-compromised states. Single warts are most common, but when warts coalesce, the condition is referred to as condylomata acuminata. Condylomata lata is a moist, heaped, wart-like papule that occurs in warm intertriginous areas, most commonly the gluteal folds, perineum, and perianal areas. Condylomata lata is caused by Treponema palladium infection, the causative organism of syphilis. Primary syphilis is associated with a painless ulcer (chancre) (A), which is highly infective and heals spontaneously 3 to 6 weeks after the primary infection. Chancroid (B) is associated with painful lymphadenopathy and a tender inguinal mass or abscess that forms from coalesced lymph nodes. The causative organism is Haemophilus ducreyi. Penicillin (C) is the treatment for syphilis.

3-month-old infant presents to the ED with the condition seen in the image above. Parents state the child is acting appropriately and there is no hair loss. Which of the following is true regarding this diagnosis? Antibiotics are commonly required Care must be taken to avoid transmission of the condition Steroids are the definitive treatment Supportive care with soap and water usually treats the condition

Correct Answer ( D ) Explanation: The patient has infantile seborrheic dermatitis, also known as cradle cap or honeycomb disease. It is a yellowish, patchy, greasy, scaly, crusty skin rash that occurs on the scalp of recently born babies. Pruritus is uncommon, and the infant is not bothered. Cradle cap most commonly begins sometime in the first 3 months of life. It is not exactly clear what causes cradle cap, but the 2 most common hypotheses include fungal infection with Pityrosporum ovale, newly renamed Malassezia furfur, and overactive sebaceous glands. The adult version of cradle cap is seborrheic dermatitis. The onset of seborrheic dermatitis usual occurs at puberty. It peaks at age 40 years and is less severe, but present, among older people. Treatment in infants is supportive with gentle washing with soap and water. Bacteria do not cause the condition, so antibiotics (A) will not be useful unless a secondary bacterial infection develops. The condition is not contagious (B). Steroids (C) should be avoided in infants due to the potential for systemic absorption.

A 17-year-old girl with no past medical history presents with pain and swelling to the left axilla for 3 days. She states this has never happened before. Physical examination reveals a 3 cm area of swelling and tenderness in the axilla with no warmth or erythema. The area is fluctuant. Which of the following represents the appropriate management? Amoxicillin and follow up Ciprofloxacin and follow up CT scan with contrast Incision and drainage

Correct Answer ( D ) Explanation: The patient presents with an uncomplicated, simple cutaneous abscess, which should be treated with incision and drainage (I&D). A simple cutaneous abscess is a localized collection of pus that results in a fluctuant soft tissue mass. They can occur in any part of the body but are most commonly found in the neck, axilla and perirectal areas. Most abscesses contain bacteria but up to 5% of them are sterile. This is most commonly seen in patients with parenteral drug abuse. The majority of cutaneous abscesses are caused by skin flora and Staphylococcus aureus is the most commonly cultured aerobic agent. Abscesses near mucous membranes (perioral and perirectal) tend to predominantly be caused by anaerobic bacteria. The standard treatment for cutaneous abscesses is incision and drainage. In patients with normal immune systems and minimal erythema after drainage, antibiotics are not indicated. For I&D, the incision should be made to adequate length and depth to ensure complete drainage. The cavity is typically left open with or without a wick for drainage. Treatment with antibiotics alone (A & B) is inadequate as the antibiotic will not be able to adequately penetrate the abscess cavity to eliminate the infection. CT scan with contrast (C) is not indicated in the workup of a simple cutaneous abscess.

A 54-year-old man presents to the ED complaining of back pain. He states that over the previous two days he developed a headache, cough, and runny nose. You perform a physical examination and note lesions as seen in the picture above. What is the cause of this skin condition? Herpes simplex virus Morbillivirus Roseolovirus Varicella-zoster virus Variola

Correct Answer ( D ) Explanation: The rash is consistent with shingles, which is due to reactivation of the latent varicella-zoster virus. This condition is most often seen in older individuals. The classic rash is dermatomal in distribution and is often described as grouped vesicles on an erythematous base. The lesions remain in congruent stages of healing as compared to chicken pox (varicella) that exhibits multiple stages of healing. Infection begins as a prodrome of headache, photophobia, malaise, and itching and burning in the affected area 1-3 days before the appearance of the rash. Herpes simplex virus (A) is responsible for similar skin lesions defined by their small, thin-walled grouped vesicles on an erythematous base. Herpes simplex I typically causes oral lesions, whereas herpes simplex 2 mainly causes genital lesions. The virus that causes measles (B) is part of the Morbillivirus genus. The characteristic measles rash is described as a generalized, maculopapular, erythematous rash that begins several days after the onset of fever. It starts on the head before spreading to cover most of the body, often causing itching. The rash is said to change color from red to dark brown before disappearing. Roseolovirus (C) is responsible for the childhood condition roseola. Roseola is characterized by several days of high fever that resolves just as a pale, pink macular rash develops on the face, neck, and chest. Variola (E) is the causative agent for smallpox. This rash begins as small red spots on the tongue and in the mouth and develops into sores that spontaneously rupture. Around the third day, the rash evolves into diffuse, raised bumps with subsequent appearance of pustules that are round, sharply defined, and firm to the touch.

A healthy 7-year-old girl presents with the rash seen above. What management is indicated? Clotrimazole Dicloxacillin Meropenem Mupirocin

Correct Answer ( D ) Explanation: This child presents with a mild case of impetigo and can be treated with topical mupirocin. The rash is characterized by a slowly progressing pustular eruption and is commonly seen in preschool age children. The most common causative agent is Staphylococcus aureus with group A streptococcus as a less common etiology. It most commonly presents on the face and other exposed areas and typically begins with a single pustule that develops into multiple lesions over time. The original erythematous vesicle will break leaving red erosions covered in a golden yellow crust. The lesions should not be painful but may be pruritic. The lesions are contagious. First line treatment for limited extent of lesions is with topical antibiotics including mupirocin 2% ointment. Mupirocin should not be used if methicillin-resistant strains are suspected. Meropenem (C) is a broad spectrum antibiotic that can only be administered intravenously. Although it is effective against the bacteria that cause impetigo, this patient should be treated with an oral or topical agent. Clotrimazole (A) is an antifungal agent that would not be helpful in the treatment of impetigo. Dicloxacillin (B) is a semisynthetic penicillin that is indicated for the treatment of extensive bullous impetigo but not for pustular impetigo.

A 43-year-old man presents with pain, swelling, and redness to his left leg for two days. He denies fever or history of similar presentations in the past. He was hospitalized a month ago for three days. Vital signs are unremarkable. Physical examination reveals a 3 cm area of erythema, warmth, and purulence on the left shin. What treatment is recommended? Amoxicillin-clavulanate Cephalexin Ciprofloxacin Trimethoprim-sulfamethoxazole (TMP-SMX)

Correct Answer ( D ) Explanation: This patient presents with signs and symptoms of cellulitis requiring antibiotic treatment covering the most likely pathogens. Cellulitis is a soft tissue infection involving the skin and subcutaneous tissue. It is characterized by erythema, swelling, local warmth and tenderness. Cellulitis can occur anywhere on the body but usually presents on the lower extremities, upper extremities and face. Staphylococcus aureus and Streptococcus pyogenes are the most commonly isolated organisms and antibiotics should be directed against these pathogens. The diagnosis is made clinically and there is no specific test that aides in diagnosis. Standard treatment is with immobilization, elevation, warm compresses and antibiotics. In the last 10-15 years, community acquired methicillin resistant S. aureus (CA-MRSA) has become a common causative organism. Cephalexin is a first generation cephalosporin with activity against many streptococcus and staphylococcus species but not against MRSA. TMP-SMX is active against most strains of MRSA but does not have adequate activity against S. pyogenes. Per IDSA guidelines, for outpatients with purulent cellulitis (e.g., cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess), empirical therapy (e.g. TMP-SMX) for CA-MRSA is recommended pending culture results. Empirical therapy for infection due to β-hemolytic streptococci is likely to be unnecessary. Amoxicillin-clavulanate (A) ​does not provide coverage against MRSA and is not recommended in treatment of purulent cellulitis. Cephalexin alone (B) is adequate for non-purulent cellulitis but is inadequate when there is purulence because it is not active against MRSA. Ciprofloxacin (C) is not active against streptococcus species or MRSA.

A 4-year-old boy who is otherwise healthy presents to the ED with his mother complaining of nausea and colicky, generalized abdominal pain. Last week he was seen by his pediatrician for knee pain and constipation. His vital signs are within normal limits. On exam, his abdomen is mildly tender. What exam or test is most likely to reveal the diagnosis? Abdominal radiograph Abdominal ultrasound Digital rectal exam Undressed skin exam

Correct Answer ( D ) Explanation: This patient's clinical presentation is consistent with Henoch-Schönlein purpura (HSP). HSP is an immune-mediated (IgA predominantly), small-vessel vasculitis twice as common in males than in females. It has a peak incidence between ages of 3 and 10 years. Multiple organ systems are typically involved, including renal, GI, and musculoskeletal. The characteristic palpable purpura is invariably present and tends to appear on the buttocks though the involvement of the abdomen and extremities may also be noted. Lower extremity arthralgias are the most common musculoskeletal complaint. GI involvement may cause simple colicky abdominal pain, nausea, or bloody stools. Providers who fail to undress the patient classically miss the diagnosis. An abdominal radiograph (A) and ultrasound (B) will most likely be normal in HSP. A digital rectal exam (C) may reveal guaiac negative or positive stool in HSP.

A 64-year old man presents with right-sided abdominal pain and the following rash. Which of the following is the most likely diagnosis? Coxsackie A16 Herpes simplex type 1 Rubeola Varicella zoster

Correct Answer ( D ) Explanation: Varicella Zoster is the cause of both varicella (chickenpox) and zoster (shingles). Chickenpox is generally an infection of childhood that is characterized by a vesicular rash in crops of varying stages. The transmission is via respiratory droplets and contact with ruptured vesicles. Shingles is a reactivation of the latent virus from the dorsal root ganglia. Shingles can occur at all ages but is most commonly seen in patients older than 50 years. Shingles presents in a unilateral dermatomal distribution of vesicles. It is associated with pain and burning that may precede the eruption by up to 72 hours. The rash evolves quickly from an erythematous, maculopapular eruption to a cluster of vesicles. The duration of illness is usually 7-10 days. Transmission is by contact with the ruptured vesicles and via respiratory droplets. Treatment consists of oral anti-viral medications (acyclovir or valacyclovir), aluminum acetate soaks and pain control. Vaccines are available for both chickenpox and shingles. The shingles vaccine is indicated in patients older than 60 years, and in some patients older than 50 years. Coxsackie (A) commonly known as hand-foot-mouth disease. It is a highly contagious viral entity commonly seen in children. Lesions are ulcerative on the oral mucosa, palms and soles. Epidemics are common in the summer months when children are playing together in public pools. Herpes simplex type 1 (B) is a virus capable of producing a variety of infections of the skin, genitalia, and CNS. Primary infections have a flu-like prodrome. HSV 1 infection usually occurs on the oral mucosa. It can present as a cluster of vesicles on, above, or below the lips and can be preceded by tingling in the area of reactivation. Rubeola (measles) (C) is a viral illness characterized by a prodrome of fever, conjunctivitis, and coryza followed by a generalized maculopapular rash that begins behind the ears and descends down the body.

A diabetic man arrives in the ED with a hand laceration sustained while preparing raw shellfish. Hemorrhagic bullae are noted immediately proximal to the wound site. Which of the following type of organism is most likely responsible? Aeromonas hydrophila Pseudomonas aeruginosa Staphalococcus aureus Vibrio vulnificus

Correct Answer ( D ) Explanation: Vibrio vulnificus infection should be suspected in patients with a history of ingestion of raw seafood (most commonly oysters) or wound infection after exposure to seawater. Patients who ingest raw seafood report abrupt GI symptoms such as vomiting, diarrhea, or abdominal pain, and may present with fever, chills, or shock. Patients who are exposed to Vibrio vulnificus after handling raw seafood can develop a rapid cellulitis that progresses to hemorrhagic bullae and purpura fulminans, which are most commonly found on the trunk and the lower extremities. Though rare, Vibrio vulnificus can cause necrotizing fasciitis and septicemia, necessitating immediate and intensive empirical antibiotic treatment with surgical debridement in suspected cases. Aeromonas hydrophila (A) is a bacteria associated with freshwater exposure, typically lakes and slow moving streams. As with Vibrio vulnificus, it can lead to serious wound infections including limb-threatening necrotizing fasciitis. Staphylococcus aureus (C) is responsible for many cutaneous infections but generally does not cause hemorrhagic bullae. Pseudomonas aeruginosa (B) thrives in a wide-range of environments. Diabetics have a greater propensity to contract a pseudomonal infection. However, it is not associated with raw shellfish or hemorrhagic bullae.

A 75-year-old man presents with left eye redness and continuous tearing for two days. He has a foreign-body sensation in his eye with no history of trauma. On exam, you note vesicular skin lesions limited to the left side of his forehead. Slit lamp exam reveals corneal ulceration and pseudodendrites. Which of the following is true regarding his condition? Bilateral forehead involvement is more common than unilateral involvement Cranial nerve VII impairment is always present Herpes simplex virus is the cause of this condition Hutchinson's sign is indicative of nasal septum involvement Punctate epithelial keratitis is the most common associated corneal lesio

Correct Answer ( E ) Explanation: The patient has herpes zoster ophthalmicus, which is caused by the varicella zoster virus (VZV). The virus lies dormant within the trigeminal (V) ganglion and can reactivate and spread through the ophthalmic division of the trigeminal nerve (V1). The most common corneal lesion is punctate epithelial keratitis, where the cornea takes on a ground-glass appearance due to stromal edema. Pseudodendrites are also associated with zoster ophthalmicus and are typically located in the periphery. Pseudodendrites stain poorly with fluorescein and, unlike true dendrites, lack rounded terminal bulbs. Cranial nerve VII (B) is often involved in Bell's palsy. It may also be seen with zoster cephalicus (i.e., Ramsay-Hunt syndrome), whereas zoster ophthalmicus is isolated to the trigeminal nerve (CN V). Varicella zoster (C) is the virus that causes zoster ophthalmicus. Because the nasociliary branch innervates the globe, the most serious ocular involvement develops if this branch is affected. Classically, involvement of the tip of the nose (Hutchinson's sign) (D) has been thought to be a clinical predictor of ocular involvement. Although patients with a positive Hutchinson's sign have twice the incidence of ocular involvement, one-third of patients without the sign develop ocular manifestations.The skin manifestations of herpes zoster ophthalmicus strictly obey the midline (A) with involvement of one or more branches of the ophthalmic division of the trigeminal nerve, namely the supraorbital, lacrimal, and nasociliary branches.

A 55-year-old man presents with right sided chest pain and a rash for four days as seen above. What management should be initiated? Diphenhydramnine Pain control Topical antibiotics Topical corticosteroids

orrect Answer ( B ) Explanation: This patient presents with herpes zoster (shingles) and should have appropriate pain control started. Herpes zoster results from the reactivation of dormant varicella zoster virus developing in patients with a history of chickenpox. Typically, pain in a dermatomal distribution precedes the eruption of grouped vesicles on an erythematous base in the same dermatome. The vesicles are cloudy at first and progress to crust formation later in the course. The pain associated with the disease is often severe and debilitating. Patients may have chronic post-herpetic neuralgia as well. The mainstay of treatment is pain control and oral antiviral medications. Orally administered corticosteroids were commonly recommended in the treatment of herpes zoster, but given recent clinical trials showing variable results, they are not usually recommended. Diphenhydramine (A) has not been shown to hasten the rate of healing in patients with varicella zoster. Topical antibiotics (C) are only indicated if there is a superinfection of the lesions. Topical corticosteroids (D) have not been shown to be beneficial.