skin conditions that sometimes require an er · zoster ophthalmicus, varicella with systemic...

James R. Jacobs, M.D., Ph.D.Executive Director, Vaden Health Center

Associate Vice Provost for Student Affairs

Associate Professor of Psychiatry and Behavioral Sciences and Emergency Medicine

Stanford University

ACHA Annual Meeting | Austin | 2 June 2017

Skin Conditions that Sometimes Require an ER

Disclosures

CONFLICT OF INTEREST

I have NO actual or potential conflict of interest in relation to this

educational activity or presentation.

There is no financial support for this presentation from any entity.

OFF-LABEL USE OF MEDICATIONS

I do not anticipate discussing the unapproved use of commercial

products during this presentation.

SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER

3

Learning Objectives Content

DESCRIBE DANGEROUS BACTERIAL SKIN

CONDITIONS

DESCRIBE DANGEROUS VIRAL SKIN

CONDITIONS

DESCRIBE DANGEROUS IMMUNOLOGICAL

AND INFLAMMATORY SKIN CONDITIONS

Meningococcemia, necrotizing

fasciitis, RMSF, scalded skin and

toxic shock syndromes, complicated

cellulitis, complicated cutaneous

abscess, anthrax

Multidermatomal zoster, Herpes

zoster ophthalmicus, varicella with

systemic symptoms, smallpox

DRESS syndrome, Stevens-Johnson

syndrome/toxic epidermal necrolysis,

anaphylaxis

Sick vs. Not Sick; Clinic vs. ER

Oral medication vs. IV medication


Mid-presentation questions for pharmacy credit


• Ceftriaxone is considered to be a broad spectrum

antibiotic.

• True or false

• Intravenous administration of ceftriaxone is more effective

than intramuscular administration.

• True or false

• Ceftriaxone 2 g should never be administered prior to 911

transport to the ER for a case of suspected

meningococcemia.

• True or false

Necrotizing fasciitis



• Rare but limb- and life-threatening soft-tissue infection

• Characterized by rapidly spreading inflammation and subsequent

necrosis of the fascial planes and surrounding tissue

• More accurately named necrotizing soft tissue infection

• Mortality increases with depth of infection

• 3 Proposed Types

• Polymicrobial (most common)

• Monomicrobial

• Vibrio vulnificus (worst)

• The infection typically follows a trauma

• Ranging from major surgery to injection sites to minor abrasion or

insect bite

• Often unnoticed

• Treatment is surgical debridement

• Time-to-debridement is most important factor affecting mortality



• Usually presents with the classic triad of local pain, swelling, and erythema

• Classic signs and symptoms

• Blisters and bullae form and drain

• Initially serosanguineousfollowed by hemorrhagic fluid

• Skin shows violaceous discoloration before turning frankly necrotic and sloughing

• Crepitus may be present

• Disproportionate pain is replaced by analgesia

• Tachycardia (>100 beats/min) and fever are the most common vital sign abnormalities, followed by hypotension (SAP<100 mmHg) and tachypnea (>20/min)

• Infection can spread as fast as 1 inch per hour with little change in overlying skin



• Consider the possibility

• Tenderness beyond the margins of the visible problem

• Pain out of proportion to the visible problem

• Crepitus

• Rapid worsening

• Be especially wary if this is the 2nd or 3rd visit for the same acute,

initially minor skin problem


Multidermatomal Herpes Zoster

Reactivation of varicella zoster virus

involving the dermatomes supplied by

the first branch (V1) of the trigeminal

nerve ganglion with ocular involvement


Herpes zoster ophthalmicus

Reactivation of varicella zoster virus

involving the dermatomes supplied by

the first branch (V1) of the trigeminal

nerve ganglion with ocular involvement


Herpes zoster ophthalmicus



4 cm


Smallpox Varicella

Smallpox


Meningococcemia

Most patients infected with N meningitidis present with acute illness

Early symptoms reported by patients with meningococcal meningitis

and/or meningococcemia are often nonspecific (e.gg, fever, headache,

malaise) and challenge the early diagnosis of a meningococcal infection

The classic triad of fever, meningismus, and altered mental status is

observed in only one-third of patients with meningococcal meningitis at

presentation

Characteristic petechial rash is a more specific finding, but it is observed

in only 45% to 65% of cases at presentation

Although up to one-quarter of patients with meningococcal meningitis

have focal neurologic deficits (eg, aphasia, cranial neuropathies), these

are late findings, and their absence cannot be used to rule out a diagnosis

of meningitis


Meningococcemia

• Cutaneous findings in meningococcemia are not consistently presents

• In one series of adult patients, 50% had no cutaneous findings

• When present, skin findings are not specific

• Morbilliform eruptions, papules, and vesicles may occur early in the

disease, then purpura subsequently develops


Meningococcemia

• Palpable purpura is a raised, non-blanchableerythema and signifies extravasation of red cells outside of blood vessels

• Vasculitis, regardless of its cause, most commonly presents as palpable purpura

• This distinctive petechial rash occurs as a result of endotoxin-induced damage to endothelial cells and attendant thrombosis, necrosis, and eventually dermal hemorrhage

• In meningococcemia, purura may progress to purpura fulminans, disseminated intravascular coagulation, and thromboses

• Although the petechial rash is a characteristic finding in patients with severe disease, a similar rash may also be observed in other febrile conditions such as Rocky Mountain spotted fever, severe DIC (due to other causes), thrombotic thrombocytopenic purpura, Henoch-Schonlein purpura, and other vasculitides


Mid-presentation questions for pharmacy credit


• Ceftriaxone is considered to be a broad spectrum

antibiotic.

• True or false

• Intravenous administration of ceftriaxone is more effective

than intramuscular administration.

• True or false

• Ceftriaxone 2 g should never be administered prior to 911

transport to the ER for a case of suspected

meningococcemia.

• True or false

skin conditions that sometimes require an er · zoster ophthalmicus, varicella with systemic...

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