Dermatologic Manifestations of Infectious Diseases Jessica Newman, DO Division of Infectious Diseases

Doctor, I have this rash…

Other characteristics Skin lesions - terms Type of skin lesion Raised Flat Depressed Papule Macule Erosion Plaque Patch Ulcer Nodule Erythema Atrophy Cyst petechiae  Striae Wheal   Burrow  Scar Horn Other characteristics Shape round, oval, annular, reticulated, linear, serpiginous, umbilicated Color of skin lesion white (leukoderma, hypomelanosis), red/pink (erythematous), violaceous (vascular, ecchymotic) Consistency soft, firm, fluctuant Arrangement Grouped herpetiform/zosteriform, arciform, linear, serpiginous, Disseminated scattered discrete lesions or diffuse involvement Distribution Extent isolated, localized, generalized Pattern symmetrical, exposed areas, intertriginous, including palms/soles

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Classification/type of lesion Raised Flat Depressed Surface Change Fluid-Filled Vascular Papule Macule Erosion Scale Vesicle Petechiae Plaque Patch Ulcer Crust Pustule Purpura Nodule Erythema Atrophy Excoriation Bulla Telangiectasia Cyst Striae Fissure Furuncle Infarct Wheal Burrow  Eschar Abscess   Scar Lichenification  Horn Notes – can “google image” additional examples if not described below: Raised - A papule is a solid, elevated lesion less than 0.5 cm in size in which a significant portion projects above the plane of the surrounding skin Plaque is plateau-like and larger than a papule (may be confluence of papules) Nodule is > 0.5 cm and can extend under the skin Flat: Macule = spot (small) – patch is larger Erythema = redness Surface change: scale– excess skin (stratum corneum) layers Crust - fluid dried on surface Excoriated – scratch Fissure – deep crack Fluid-filled: Vesicle is filled with clear fluid; pustule with opaque (pus) – size <0.5 cm Bullae is > 0.5 cm

Approach to Dermatologic Diagnosis Initial clinical impression (by history/systemic examination) Classification/type of lesion Shape (& color) of individual lesions Consistency and feel of lesion Arrangement of multiple lesions Distribution of multiple lesions Anatomic components of the skin primarily affected

Shape (description) of lesions ulcer crust papule vesicle bullae nodule macule plaque pustule Fitzpatrick's Dermatology in General Medicine, 7th Edition

Describe the dermatologic condition CC: Rash Describe the dermatologic condition Plaques Circular/irregular shape Pink Smooth Randomly dispersed Superficial http://www.webmd.com/children/ss/slideshow-common-childhood-skin-problems

Skin Structure © 2009 WebMD, LLC. All rights reserved.

Superficial primary skin infections Superficial dermatoses, erythrasma, pyoderma, cellulitis, fasciitis Tinea corporis – Patch, oval, pink-red (erythematous), scaling Cutaneous candidiasis – Plaque, circular/irregular, erythematous, with mild scaling and erythematous satellite papules

Primary Skin Infection Deeper dermis and subcutaneous fat Cellulitis

Erysipelas Infx with beta-hemolytic streptococci – involves Upper dermis and lymphatics

Streptococcal infections GAS Scarlet Fever GAS Toxic shock syndrome Erythroderma with desquamation Scarlet fever (also known as ‘scarlatina’) is a diffuse erythematous eruption that generally occurs in association with pharyngitis. Development of the scarlet fever rash requires prior exposure to S. pyogenes and occurs as a result of delayed-type skin reactivity to pyrogenic exotoxin (erythrogenic toxin, usually types A, B, or C) produced by the organism. The rash of scarlet fever is a diffuse erythema that blanches with pressure, with numerous small (1 to 2 mm) papular elevations, giving a "sandpaper" quality to the skin. It usually starts on the head and neck and is accompanied by circumoral pallor and a strawberry tongue. Subsequently the rash expands rapidly to cover the trunk followed by the extremities and ultimately desquamates the palms and soles are usually spared. The rash is most marked in the skin folds of the inguinal, axillary, antecubital, and abdominal areas and about pressure points. It often exhibits a linear petechial character in the antecubital fossae and axillary folds, known as Pastia's lines

Meningococcemia

Purpura Fulminans Meningococcemia Capnocytophaga sepsis Inherited protein C deficiency 15

Varicella Zoster Virus Primary infection - Chickenpox DNA Member of the Herpes family VZV prodrome: Primary infection: Fever, malaise, loss of appetite, sore throat Zoster: localized burning pain Rash Primary: Papules->vesicle->crust; begins centrally and moves outward Zoster: dermatomal

Herpes Zoster Vesicles on erythematous base

“Poxes” Smallpox Chickenpox Variola virus; a DNA orthopoxvirus within the Poxviridae family Lesions are all in same stage Double-stranded, linear DNA herpesvirus Lesions appear in a variety of stages Vesicle

Rocky Mountain Spotted Fever 19

Rocky Mountain Spotted Fever R. rickettsii infects endothelial cells causing vasculitis Rash Typically occurs 2-4 days after fever Begins ankles, wrists and forearms, palms and soles, then spreads centrally Evolves to petechial lesions Organism is not evident on blood smears

Ehrlichiosis Infects monocytes and replicates in cytoplamic membrane-bound vacuoles Rash Much less common (30-40% HME and 1/40 in HE) appears at approx 5 days Can be maculopapular, macular or petechial

“Maculopapular rash”… Henoch-Schönlein purpura Acute HIV Secondary syphilis Measles 22

Secondary Syphilis

Parvovirus B19 Erythema Infectiosum or Fifth Disease

Sporotrichosis An ulcerated nodule is seen on the thumb, with proximal lymphangitic spread represented by subcutaneous nodules Fitzpatrick’s Dermatologic in General Medicine, 7th Ed 25

Blastomycosis 26

Histoplasmosis PAS-stained smear showing degenerating H. capsulatum organisms on a necrotic background http://www.mjmsr.net/viewimage.asp?img=MullerJMedSciRes_2015_6_1_72_146470_f2.jpg 27

Mycobacterium marinum Verrucous, violaceous plaque with central spontaneous clearing occurring at the site of an abrasion sustained in a fish tank. The lesion was caused by M. marinum. 28

Disseminated Cryptococcus Infection

Primary Skin Disorders https://www.aad.org/public/diseases/scaly-skin/psoriasis http://www.oregonmedicalresearch.com/patients/active-studies/atopic-dermatitis/ Psoriasis Eczema

Rheumatic disease/Autoimmune disease IgA vasculitis Systemic Lupus erythematosus

Cancer-related Gottron’s papules Tripe Palm Heliotrope rash https://www.uptodate.com/contents/image?imageKey=DERM%2F61955&topicKey=DERM%2F7606&rank=1~150&source=see_link&search=paraneoplastic%20skin Heliotrope rash Dermatomyositis Acanthosis nigricans

Want to learn more about dermatology? Fitzpatricks Color Atlas and Synopsis of Clinical Dermatology, Eighth Edition / Edition 8 by Klaus Wolff, Richard Johnson