Download - Mucocutaneous Symptom Complex Part 2
AN OVERVIEW OF
MUCOCUTANEOUS SYMPTOM COMPLEX
Part 2
ANTONIO E. CHAN, M.D.
Classification
• Maculopapular eruption
• Vesiculobullous or vesiculopustular
• Petechial or purpuric eruption
Definition & Pathogenesis
Blisters are circumscribed elevated lesions filled with clear fluid
– Vesicles measure 5 mm or less in
diamter
– Bullae measure more than 5 mm in
diameter
Definition & Pathogenesis
• Result from a disturbance of cohesion of
epidermal cells or components of the
basement membrane zone associated
with influx of fluid into or beneath the
site of disturbance
Definition & Pathogenesis
• Depending on the mechanisms
responsible for their formation, blisters
can contain a combination of
edematous or lymphatic fluid, serum
proteins, antigen-antibody complexes,
and soluble inflammatory mediators.
Pertinent Questions To Ask
• Patient’s age
• Season
• Exposure to infectious agents or medications
• History of previous disease
• Concurrent signs & symptoms
• Morphology, distribution and evolution of the
rash
Viral Etiology of Vesiculobullous Lesions
• Varicella-zoster (wild and vaccine strains)
• Herpes simplex virus type 1 & 2
• Coxsackievirus A4, A5, A7-10, A16 & B1-3, B5
• Echovirus 4, 6, 9, 11, 17, 19, 33
• Enterovirus 7, 2
• Molluscum contagiosum
Bacterial Etiology of Vesiculobullous Lesions
• Staphylococcus aureus– Bullous impetigo– Scalded skin syndrome
• Ritter’s disease• Lyell disease
• Streptococcus pyogenes– Blistering distal dactylitis– Ecthyma– Erysipelas– Non-bullous impetigo– Scalded skin syndrome
• Disseminated gonococcal infection
Non-infectious Etiology of Vesiculobullous Lesions
• Stevens-Johnson syndrome
• Thermal injury
• Arthropod bites (Cimex spp.[bedbug],
Sarcoptes scabies)
• Contact dermatitis
VARICELLA
Skin lesions at various stages of evolution
VARICELLA
“dew drop-like lesions”
HERPES ZOSTER (SHINGLES)
ACUTE HERPETIC GINGIVOSTOMATITIS
Herpetic whitlow
MOLLUSCUM CONTAGIOSUM (WART)
Umbilicated lesions
IMPETIGO CONTAGIOSA
STAPHYLOCOCCAL SCALDED SKIN SYNDROME
Sunburst radial pattern
Positive Nikolsky sign
DISSEMINATED GONOCOCCAL INFECTION (ARTHRITIS-DERMATITIS SYNDROME)
Discrete tender necrotic pustules with erythematous base
Arthritis
ERYTHEMA MULTIFORME(STEVENS-JOHNSON SYNDROME)
Cutaneous lesions are symmetric,
in crops and show predilection for
the extensor surfaces of the hands,
arms, feet, legs, palms and soles
ERYTHEMA MULTIFORME(STEVENS-JOHNSON SYNDROME)
Viral Etiology of Petechial or Purpuric Lesions
• Dengue virus (DHF)
• Measles virus (Black measles)
• Rubella virus (Congenital rubella
syndrome)
• Enterovirus
Bacterial Etiology of Petechial or Purpuric Lesions
• Neisseria meningitidis (Septicemia)
Non-infectious Cause
• Henoch Scholein Purpura
Aedes aegypti
Dengue transmitted by Dengue transmitted by
infected female mosquitoinfected female mosquito
Primarily a daytime feederPrimarily a daytime feeder
Lives around human Lives around human
habitationhabitation
Lays eggs and produces Lays eggs and produces
larvae preferentially in larvae preferentially in
artificial containers with clean artificial containers with clean
stagnant waterstagnant water
Undifferentiated fever – may be the Undifferentiated fever – may be the
most common presentation*most common presentation*
Classic dengue feverClassic dengue fever
Dengue hemorrhagic fever (DHF)Dengue hemorrhagic fever (DHF)
Dengue shock syndrome (DSS)Dengue shock syndrome (DSS)
Dengue Clinical PresentationsDengue Clinical Presentations
In infants and young childrenIn infants and young children
– Undifferentiated febrile illnessUndifferentiated febrile illness
– Maculopapular rashMaculopapular rash
– Petechiae and a positive tourniquet test, Petechiae and a positive tourniquet test,
not uncommonnot uncommon
Clinical Characteristics of Dengue Fever Clinical Characteristics of Dengue Fever
Clinical Characteristics of Dengue Fever Clinical Characteristics of Dengue Fever
Older childrenOlder children
– Mild febrile illness, orMild febrile illness, or
– High fever withHigh fever with
Severe headacheSevere headache
Pain behind the eyesPain behind the eyes
Muscle and joint painsMuscle and joint pains
RashRash
Petechiae and a positive tourniquetPetechiae and a positive tourniquet test test
Fever, or recent history of acute feverFever, or recent history of acute fever
Hemorrhagic manifestationsHemorrhagic manifestations
Low platelet count (100,000/mmLow platelet count (100,000/mm33 or less) or less)
Objective evidence of “leaky capillaries:”Objective evidence of “leaky capillaries:”
elevated hematocrit (20% or more over baseline)elevated hematocrit (20% or more over baseline)
low albuminlow albumin
pleural or other effusionspleural or other effusions
Clinical Case Definition forClinical Case Definition forDengue Hemorrhagic FeverDengue Hemorrhagic Fever
4 Necessary Criteria4 Necessary Criteria
4 criteria for DHF4 criteria for DHF
Evidence of circulatory failure manifested Evidence of circulatory failure manifested
indirectly by all of the following:indirectly by all of the following:
Rapid and weak pulseRapid and weak pulse
Narrow pulse pressure (Narrow pulse pressure (20 mm Hg) 20 mm Hg) OR OR
hypotension for agehypotension for age
Cold, clammy skin and altered mental statusCold, clammy skin and altered mental status
Frank shock is direct evidence of circulatory Frank shock is direct evidence of circulatory
failurefailure
Clinical Case Definition for Clinical Case Definition for Dengue Shock SyndromeDengue Shock Syndrome
Tourniquet Test
• Inflate blood pressure cuff
to a point midway between
systolic and diastolic pressure
for 5 minutes
• Positive test:
20 or more petechiae
per 1 inch2 (6.25 cm2)
Grade Manifestations
I FeverNon-specific constitutional symptomssuch as anorexia, vomiting & abdominal pain
II Manifestations of grade I plus Spontaneously bleeding
III Manifestations of grade II plus Circulatory failure
IV Manifestations of grade III plus Profound shock
Dengue Hemorrhagic FeverDengue Hemorrhagic FeverGrading the SeverityGrading the Severity
Skin hemorrhages: Skin hemorrhages:
petechiae, purpura, ecchymosespetechiae, purpura, ecchymoses
Gum bleedingGum bleeding
Nose bleedingNose bleeding
Gastro-intestinal bleeding: Gastro-intestinal bleeding:
hematemesis, melena, hematocheziahematemesis, melena, hematochezia
HematuriaHematuria
Increased menstrual flowIncreased menstrual flow
Hemorrhagic Manifestations of DengueHemorrhagic Manifestations of Dengue
Dengue rash with blanching
DENGUE HEMORRHAGIC FEVER
Herman’s rash
Meningococcal Infection
• Serogroups A, B, C, D, H, I, K, L, S, Y, Z, W135 & 29E
A, B, C account for more than 90% of meningococcal
disease worldwide
• The human nasopharynx is the only natural reservoir
• Transmission: respiratory droplet and requires close and
direct contact.
• Asymptomatic carriers are the most common source of
transmission
Meningococcal Infection
• The spectrum of disease ranges from
asymptomatic transient bacteremia which
clears spontaneously to fulminant sepsis
resulting in death only a few hours after the
first symptoms occur
• The incubation period of invasive disease is
short
Meningococcal Infection
• Risk factors associated with invasive disease
Host factors
– Young age
– Crowding
– Lower socio-economic class
– Concurrent upper respiratory infection
– Specific immune deficiencies (properdin or terminal
complement)
– Functional or anatomical asplenia
– Smoking (active or passive)
Meningococcal Infection
• Risk factors associated with invasive disease
Pathogen factors
– Lipo-oligosaccharide (LOS) – pontent endotoxin
– Hypervariability of surface antigen
MENINGOCOCCAL INFECTION
Meningococcal infection
Meningococcemia
WATERHOUSE FREDERICHSEN SYNDROME
Hemorrhagic Measles(Black Measles)
• A rare but fatal occurrence
• Characterized by sudden onset of high fever
accompanied by seizure or altered mental
state
• Pneumonia, hemorrhagic exanthem &
enathem
• Bleeding from the mouth, nose,
gastrointestinal tract & probable DIC
HENOCH SCHONLEIN PURPURA
• A vasculitis of small vessels
• Etiology unknown
• Typically follows URTI
• 2 – 8 yr. of age
• Skin lesions appear in crops
• Rash begins as pinkish
maculopapules initially blanch
on pressure and progress to
petechiae or palpable purpura
(red – purple – rusty brown)
• Predilection over the dependent
areas or areas of greater tissue
distensibility
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