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(BQ) Part 1 book MCGraw-Hill specialty board review dermatology - A pictorial review presents the following contents: Hair findings, eye findings, nail findings, oral pathology, genital dermatology, autoimmune bullous diseases, pigmentary disorders, disorders of fat, cutaneous tumors, vascular tumors and malformations,...
McGraw-Hill SPECIALTY BOARD REVIEW Dermatology A Pictorial Review NOTICE Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in 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McGraw-Hill’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise CONTENTS CONTRIBUTORS / VII PREFACE / XI CHAPTER CHAPTER HAIR FINDINGS / PIGMENTARY DISORDERS / 143 Paradi Mirmirani Jason H Miller and Asra Ali CHAPTER EYE FINDINGS / 17 Brenda Chrastil-Latowsky and Syed Azhar CHAPTER NAIL FINDINGS / 35 CHAPTER 10 DISORDERS OF FAT / 159 Asra Ali and Jennifer Krejci-Manwaring CHAPTER 11 CUTANEOUS TUMORS / 171 John Cangelosi, Doina Ivan, and Alexander J Lazar Ravi Ubriani CHAPTER 12 CHAPTER ORAL PATHOLOGY / 53 MELANOMA AND NON-MELANOMA SKIN CANCER / 193 Kamal Busaidy and Asra Ali Sumaira Aasi and Katherine M Cox CHAPTER CHAPTER 13 GENITAL DERMATOLOGY / 71 VASCULAR TUMORS AND MALFORMATIONS / 207 Jennifer Krejci-Manwaring and Nishath Ali Denise W Metry, John C Browning, and Asra Ali CHAPTER CONTACT DERMATITIS / 81 Melissa A Bogle and Giuseppe Militello CHAPTER 14 GENODERMATOSIS / 221 Joy H Kunishige, Marziah Thurber, Adrienne M Feasel, and Adelaide A Hebert CHAPTER AUTOIMMUNE BULLOUS DISEASES / 97 CHAPTER 15 Whitney High PEDIATRIC DERMATOLOGY / 253 John C Browning, Denise W Metry and Adrienne M Feasel CHAPTER DISORDERS OF CORNIFICATION, INFILTRATION, AND INFLAMMATION / 111 Katherine M Cox, Rakhshandra Talpur, and Victoria G Ortiz CHAPTER 16 CUTANEOUS INFESTATIONS / 267 Dirk M Elston, Asra Ali and Melissa A Bogle vi CONTENTS CHAPTER 17 CHAPTER 26 VIRAL DISEASES / 285 COSMETIC DERMATOLOGY / 497 Natalia Mendoza, Sara Goel, Brenda L Bartlett, Aron J Gewirtzman, Anne Marie Tremaine, and Stephen K Tyring Rungsima Wanitphakdeedecha, T Minsue Chen, and Asra Ali CHAPTER 27 CHAPTER 18 IMMUNOLOGY REVIEW / 525 BACTERIAL DISEASES / 321 Kurt Lu and Genevieve Wallace Steven Marcet and Asra Ali CHAPTER 28 CHAPTER 19 BASIC SCIENCES / 549 FUNGAL DISEASE / 345 Kurt Q Lu and Asra Ali Aly Raza, Melissa A Bogle, and Mark Larocco CHAPTER 29 CHAPTER 20 NUTRITION-RELATED DISEASES / 371 BIOSTATISTICS / 571 Alice Chuang, Tahniat S Syed, and Asra Ali Clare Pipkin and Asra Ali CHAPTER 30 CHAPTER 21 HISTOLOGIC STAINS AND SPECIAL STUDIES / 585 CUTANEOUS FINDINGS RELATED TO PREGNANCY / 379 Hafeez Diwan and Victor G Prieto Ronald P Rapini CHAPTER 22 CUTANEOUS MANIFESTATIONS OF RHEUMATOLOGIC DISEASES / 383 CHAPTER 31 DERMOSCOPY / 593 Robert H Johr CHAPTER 32 Asra Ali and Carolyn Bangert RADIOLOGIC FINDINGS / 619 CHAPTER 23 CUTANEOUS MANIFESTATIONS OF METABOLIC DISEASES / 407 Jason H Miller and Asra Ali Minsue Chen, Melissa A Bogle, and Asra Ali CHAPTER 33 ELECTRON MICROSCOPY / 633 Minsue Chen and Asra Ali CHAPTER 24 DERMATOLOGIC MEDICATIONS / 427 Angela A Giancola, Melissa A Bogle, and Stephen E Wolverton CHAPTER 25 CHAPTER 34 HIGH-YIELD FACTS FOR THE DERMATOLOGY BOARDS / 645 Benjamin Solky, Bryan Selkin, Jennifer L Jones, Clare Pipkin, and Samantha Carter SURGERY AND ANATOMY / 451 T Minsue Chen, Rungsima Wanitphakdeedecha, and Tri H Nguyen INDEX / 667 CONTRIBUTORS Sumaira Aasi Samantha Carter Chapter 12 Chapter 34 Asra Ali, MD T Minsue Chen, MD Assistant Professor, Department of Dermatology, University of Texas at Houston, Houston, Texas Chapters 4, 9, 10, 13, 16, 18, 19, 22, 23, 26, 29, 32, 33 Mohs Research in Advanced Dermatologic Surgery and Education Fellow, Department of Dermatology, University of Texas M D Anderson Cancer Center, Houston, Texas Chapters 25, 26, 32, 33 Nishath Ali, MD Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas Chapter Syed Azhar, MD Associate Professor, Department of Family Medicine, University of Texas, Medical Branch, Glaveston, Texas Chapter Carolyn A Bangert, MD Assistant Professor, Department of Dermatology, University of Texas Medical Center at Houston, Houston, Texas Chapter 22 Brenda Chrastil-LaTowsky, MD Texas Health Science Center, University of Texas M D Anderson Cancer Center, Houston, Texas Chapter Alice Chuang Chapter 29 Katherine M Cox, MD Chapters 8, 12 Brenda L Bartlett, MD Clinical Research Fellow, Center for Clinical Studies, Houston, Texas Chapter 17 Melissa A Bogle, MD Clinical Assistant Professor, Department of Dermatology, University of Texas M D Anderson Cancer Center, Houston, Texas Chapters 1, 2, 6, 16, 19, 24, 32 Hafeez Diwan, MD, PhD Assistant Professor of Dermatology, Division of Pathology and Laboratory Medicine, University of Texas M D Anderson Cancer Center, Houston, Texas Chapter 30 Dirk M Elston, MD Director, Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania Chapter 16 John C Browning, MD Fellow, Pediatric Dermatology, Baylor College of Medicine, Houston, Texas Chapter 13, 15 Adrienne M Feasel, MD Kamal Busaidy Aron J Gewirtzman, MD Chapter John J Cangelosi, MD Resident, Department of Pathology, University of Texas Medical Branch, Galveston, Texas Chapter 11 Ladera Park Dermatology, Austin, Texas Chapters 14, 15 Center for Clinical Studies, Houston, Texas Chapter 17 Angela A Giancola, MD Resident, Department of Dermatology, University of Texas at Houston Medical School, Houston, Texas Chapter 24 viii CONTRIBUTORS Sarah Goel, BA Mark LaRocco, PhD Medical Student (MSIII), Western University of Health Sciences, Pomona, California Chapter 17 Adjunct Associate Professor, Department of Pathology and Laboratory Medicine, University of Texas at Houston Medical School, Houston, Texas Chapter 19 Adelaide A Hebert, MD Professor of Dermatology and Pathology, Director of Pediatric Dermatology, University of Texas Medical School at Houston, Houston, Texas Chapter 14 Alexander J Lazar, MD, PhD Kelly L Herne, MD Assistant Professor of Pathology and Dermatology, University of Texas M D Anderson Cancer Center, Sections of Dermatopathology and Soft Tissue/Sarcoma Pathology, Sarcoma Research Center, Houston, Texas Chapter 11 Advanced Dermatology, Houston, Texas Chapter Kurt Q Lu Whitney High Chapters 27, 28 Chapter Steven Marcet, MD Doina Ivan, MD Dermatologist, Newnan Dermatology, Newnan, Georgia Chapter 18 Assistant Professor of Pathology and Dermatology, Section of Dermatopathology, University of Texas M D Anderson Cancer Center, Houston, Texas Chapter 11 Natalia Mendoza, MD Assistant Professor, Research Division, Center for Clinical Studies, Universidad El Bosque, Colombia Chapter 17 Robert H Johr, MD Denise W Metry, MD Chapter 31 Jennifer L Jones, MD Instructor in Dermatology, Harvard Medical School, Boston, Massachusetts Chapter 34 Associate Professor, Department of Dermatology and Pediatrics, Bayor College of Medicine, Houston, Texas; Chief of Service, Dermatology Service, Texas Children’s Hospital, Houston, Texas Chapters 13, 15 Giuseppe Militello, MD Robert E Jordon, MD Professor, Department of Dermatology, University of Texas at Houston Medical School, Houston, Texas Chapter Assistant Professor of Clinical Dermatology, Columbia University, New York, New York Chapter Jason H Miller, MD Assistant Professor of Dermatology, University of Texas Health Science Center, San Antonio, Texas Chapters 5, 10 Resident Physician, Department of Dermatology, University of Texas at Houston Health Science Center, M D Anderson Cancer Center, Houston, Texas Chapters 9, 23 Joy H Kunishige, MD Paradi Mirmirani, MD Department of Dermatology, University of Texas Health Science Center; Department of Dermatology, M D Anderson Cancer Center, Houston, Texas Chapter 14 Permanente Medical Group, Vallejo, California; University of California, San Francisco, California; Case Western Reserve University, Cleveland, Ohio Chapter Jennifer Krejci-Manwaring, MD ix CONTRIBUTORS Tri H Nguyen, MD Tahniat S Syed, MD, MPH Associate Professor Dermatology and Otophinolaryngology, Department of Dermatology, Division of Medicine, University of Texas M D Anderson Cancer Center, Houston, Texas Chapter 25 Assistant Professor of Pediatrics, Division of Adolescent Medicine, Department of Pediatrics, St Christopher’s Hospital for Children, Philadelphia, Pennsylvania Chapter 29 Rakhshandra Talpur, MD Victoria G Ortiz, MD Chapter Department of Dermatology, University of Texas Health Science Center, Houston, Texas Chapter Marziah Thurber, MD Mount Siani Medical Center, Miami, Florida Chapter 14 Clare Pipkin, MD Instructor, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts Chapters 19, 34 Anne Marie Tremaine Chapter 17 Victor G Prieto, MD, PhD Professor, Departments of Pathology and Dermatology, University of Texas M D Anderson Cancer Center, Houston, Texas Chapter 30 Stephen K Tyring, MD, PhD Clinical Professor, Department of Dermatology, University of Texas Health Science Center and Center for Clinical Studies, Houston, Texas Chapter 17 Ronald P Rapini, MD Professor and Chairman, Department of Dermatology, University of Texas Medical School, M D Anderson Cancer Center, Houston, Texas Chapter 21 Ravi Ubriani, MD Aly Raza, MPH, PhD Genevieve Wallace, MD Professor, Department of Dermatology, University of California at San Francisco, UCSF Medical Center, San Francisco, California Chapter 19 University of Texas Health Science Center, Houston, Texas Chapter 27 Bryan Selkin, MD Instructor of Dermatology, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts Chapter 34 Benjamin Solky, MD Winchester, Massachusetts Chapter 34 Department of Dermatology, Columbia University, New York, New York Chapter Rungsima Wanitphakdeedecha, MD Instructor, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Chapters 25, 26 Stephen E Wolverton, MD Professor of Clinical Dermatology, Department of Dermatology, Indiana State University, Indianapolis, Indiana Chapter 24 330 Fever begins to 12 weeks after bite Acute form: fevers, headache, hepatsplenomegaly, hemolytic anemia (80% of RBCs infected), depressed CD4 counts • Chronic form: verruga peruana (Fig 18-11) – Small nodules form and subsequently become larger – Vascular miliary, nodular and mular lesions form (resemble pyogenic granuloma) – Can ulcerate, bleed, and heal by fibrosis over several months – Various stages may occur together • Diagnosis: • Histology: Rocha-Lima bodies: purple cytoplasmic inclusion bodies in endothelial cells • Hemolytic anemia, thrombocytopenia, and elevated liver function studies • Treatment: chloramphenicol or doxycycline • • BRUCELLOSIS (MEDITERRANEAN FEVER, MALTA FEVER, GASTRIC REMITTENT FEVER, AND UNDULENT FEVER) • Brucella abortus, B melitensis, B suis, and B canis (aerobic gram-negative coccobacilli) • Aerosol transmission as well as through breaks in the skin, mucous membranes, conjunctiva, and respiratory and GI tracts • Infections are seen in occupations with direct or indirect exposures to animals, such as the meat-packing industry, or from unpasteurized dairy products (goat cheese) • Incubation is between 1–8 weeks • Cell wall lipopolysaccharide (LPS): principal virulence factor that enters macrophages • Infects organs of the reticuloendothelial system (i.e., liver, spleen, bone marrow) FIGURE 18-11 Verruga peruana (Reprinted with permission from Connor DH et al Pathology of Infectious Diseases Stanford, CT: Appleton & Lange; 1997, p 434.) Chapter 18 BACTERIAL DISEASES • Host response results in tissue granulomas and visceral microabscesses • Clinical • Acute fever, malaise, arthralgias • Cutaneous signs: rare granulomas, ulcerations, petechiae, purpura, and erythema nodosum • Endocarditis • Sacroiliitis, epididymoorchitis in males • Meningitis • Diagnosis: • Agglutination titers for anti-O-polysaccharide antibody • Culture (bone marrow culture much more sensitive than blood culture) • Immunoglobulin G (IgG) by ELISA • Anemia, thrombocytopenia, pancytopenia in 6% of patients • Elevated liver enzymes • Bone marrow: erythrophagocytosis • CSF reveals pleocytosis, elevated protein levels • Echocardiogram to evaluate for endocarditis • Treatment • Doxycycline and rifampin or trimethoprimsulfamethoxazole (TMP-SMZ) plus rifampin • Drain pyogenic joint effusions or rare paraspinal abscesses Leptospirosis (Weil Disease or Icteric Leptospirosis) • Leptospira interrogans (spirochete) • Incubation period is usually 7–12 days • Infects many types of mammals: cats, dogs, cattle, pigs, squirrels • Transmitted via infected urine and then through contact with contaminated water and soil • Over half of cases in the United States occur in Hawaii • Clinical • Two distinct presentations – Septicemic: organism may be isolated from blood cultures, CSF, and most tissues; patients may have myalgias, weakness as well as meningitis like symptoms (headache, photophobia) – Immune: occurs after a few days of improvement following the septicemic stage – Occurs as a result of an immune reaction to the infection – Circulating antibodies may be detected or the organism may be isolated from urine; it may not be recoverable from blood or CSF • Subclinical meningitis with headaches, fever, petechiae • Cutaneous lesions: macular or maculopapular eruption with erythematous, urticarial, petechial, or desquamative lesions, jaundice (90% of 331 TICK-BORNE BACTERIAL INFECTIONS • • • • • • patients manifest a mild anicteric form of the disease) • Vasculitis of capillaries: petechiae, intraparenchymal bleeding, and bleeding along serosa and mucosa • Organ involvement: direct hepatic injury (jaundice, hepatosplenomegaly, nausea and vomiting), alveolar capillary injury, renal tubular necrosis, myocarditis and coronary arteritis • CSF: ± encephalitis Syndromes occasionally based on species type • L autumnali: Pretibial fever (Fort Bragg fever): fevers, pretibial erythema, and ocular symptoms • L grippotyphosa: Gastrointestinal symptoms • L pomona or L canicola: aseptic meningitis: • L icterohaemorrhagiae: jaundice (83% of patients) Weil syndrome: profound jaundice, renal dysfunction, hepatic necrosis, pulmonary dysfunction, and hemorrhagic diathesis Diagnosis Serologies: microscopic agglutination test (MAT): four-fold increase Indirect hemagglutination assay (IHA): • Dark-field microscopy of blood or rising antibodies • Culture: blood, CSF, urine Treatment: tetracyclines or penicillin (possible Jarisch-Herxheimer reaction) Typhoidal (10–15% of cases) severe form with pneumonia, fever, myalgias • Diagnosis: • Blood cultures: usually normal • Serologic testing: enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR) • Treatment: aminoglycosides (streptomycin) • Considered by the CDC to be a viable weapon of bioterrorism (Category A) • Lyme Disease (Fig 18-12) • Caused by the spirochete Borrelia burgdorferi • Vector: Ixodes ticks (hard ticks) • Eastern/midwestern United States: I scapularis, I dammini • Northwestern United States: I pacificus • Europe: I ricinus and I persulcatus • Clinical • Stage 1: early localized – Erythema migrans (EM) occurs in up to 80% of cases – Erythematous macule or papule at site of the tick bite, can have central clearing – Expanding figurate erythema occurs over days to weeks – Typically resolves in about one month TICK-BORNE BACTERIAL INFECTIONS Tularemia (Ohara’s Disease, Deer Fly Fever) • Francisella tularensis (gram-negative coccobacillus) • Vectors: hard tick (Dermacentor andersoni) or deer fly (Chrysops discalis) • Reservoir: rabbits (“rabbit fever” common in hunters) • Incubation period of 3–4 days • Clinical • Eight forms: depend on mode of transmission: ulceroglandular (most common), glandular, oculoglandular, oropharyngeal, pulmonary, typhoidal, meningeal, chancriform – Intracellular parasitism of reticuloendothelial system of humans – Infection common in hunters after infected animal exposure via vectors • Ulceroglandular (70–80% of cases) – Organism enters through a scratch or abrasion – Tender papule that ulcerates with sporotrichoid spread – Regional lymphadenopathy FIGURE 18-12 Lyme disease (Reprinted with permission from Connor DH et al Pathology of Infectious Diseases Stanford, CT: Appleton & Lange; 1997, p 637.) 332 Stage 2: early disseminated disease – Hematogenous spread – Lymphocytic meningitis, cranial neuropathy, carditis (heart block, arrhythymias), and rheumatologic changes (arthralgias, oligoarthritis) – Borrelial lymphocytoma: bluish red nodular swelling that is almost always on the lobe of the ear or the areola of the nipple • Stage 3: late Lyme disease – Acrodermatitis chronica atrophicans (ACA) – 20% of patients have history of untreated erythema migrans – Develops months to 10 years later – Inflammatory phase (early) – Edema and erythema, usually on the distal extremities • Atrophic phase (late) • 5–10% of patients develop scleroderma-like plaques – Loss of subcutaneous fat, with thin, atrophic, and dry skin – Neurologic changes (meningitis, encephalitis) • Diagnosis • Antibody titer (antibodies take 4–6 weeks to develop and thus, are not usually present at the time of the rash) • Confirm positive ELISA antibody titers with PCR • False-positive results of IFA or ELISA can occur because of cross-reactivity with Treponema pallidum, and other spirochetal agents • Histology: presence of telangiectasias and cellular infiltrates of lymphocytes with admixed plasma cells; ACA demonstrates striking epidermal atrophy • Treatment • Doxycycline or amoxicillin • Pediatric patients: erythromycin • Rickettsioses • Obligate intracellular gram-negative coccobacilli • Transmitted to humans by arthropods • Spotted fever group • Rocky Mountain spotted fever • Rickettsial pox • Boutonneuse fever • Typhus group • Louse-borne (epidemic) typhus • Brill-Zinsser disease (i.e., relapsing louse-borne typhus) • Murine (endemic or flea-borne) typhus • Other rickettsial diseases • Tsutsugamushi disease (i.e., “scrub typhus”) • Q fever: Coxiella burnetii • Ehrlichia Chapter 18 BACTERIAL DISEASES ROCKY MOUNTAIN SPOTTED FEVER • Rickettsia rickettsii (obligate intracellular gram -coccobacilli) • Disease commonly found in North Carolina and Oklahoma which account for one third of total cases reported; other areas outside of the United States include Canada, Mexico, Central America, Colombia, and Brazil • Vectors • Eastern United States: wood tick (Dermacentor andersoni) • Western United States: dog tick (Dermacentor variabilis) • Clinical • Triad: fever, headache, and rash (1 to weeks after tick bite) • Multisystem involvement is common • Skin lesions – Appear two to four days following fever – Blanchable macular rash that starts on extremities and spreads to trunk (centripetal) – Face usually spared; involvement of the scrotum or the vulva and palms/soles – Erythematous macules that become petechial over a few days • “Spotless” fever in 10% of cases – Desquamation occurs as the rash fades – Systemic findings: hepatosplenomegaly, myocarditis, thrombocytopenia, CNS involvement (confusion, lethargy, ataxia, and seizures) • Rumple-Leede test – Multiple petechiae appear where sphygmomanometer or tourniquet is placed • Diagnosis • Elevated liver function tests • Blood cultures • Indirect fluorescent antibody • Direct immunofluorescence • Immunoperoxidase staining • Latex agglutination • Complement fixation • Giemsa stain • Lumbar puncture • Weil-Felix assay: agglutination of OX-strains of Proteus vulgaris with suspected rickettsia • Treatment • Tetracycline or chloramphenicol (in pediatric patients) • Avoid sulfa treatments; symptoms may worsen RICKETTSIALPOX • Caused by R akari • Vector: rodent (house mouse) mite, Liponyssoides sanguineus (formerlyAllodermanyssus sanguineus) 333 TICK-BORNE BACTERIAL INFECTIONS • Most common in boroughs of New York City (Brooklyn, Queens), found commonly in urban areas • Incubation period is 10–21 days • Clinical • Papular skin lesions appear at the bite site and then become vesicular with surrounding erythema • Dries and forms a black eschar; no scarring • Sudden onset of high-grade fever and chills (3 days after skin lesions), headaches, and myalgias • Mild and self-limited disease which persists for about a week • Diagnosis: • Cultures from blood • Direct fluorescent antibody test of biopsies from skin lesions • Immunofluorescence antibody (IFA) testing • Complement fixation • Histology: mononuclear cell infiltration and necrosis of the dermis and epidermis Perivascular inflammation with thrombi and extravasation of red blood cells • Giemsa stain of tissue: small coccobacillary intracellular bacteria • Treatment • Self-limited disease • Doxycycline or chloramphenicol, quinolones BOUTONNEUSE FEVER (MEDITERRANEAN FEVER) • Causative agent is R conorii • Vector: Rhipicephalus sanguineus (brown dog tick) • Incubation time of BF is usually 4–15 days • Clinical • Fever • Exanthem: erythematous papules, mainly on the lower limbs • Tache noire (eschar, necrotic plaque) at the site of the tick bite • Malignant form – Criteria: requires two laboratory abnormalities (thrombocytopenia, increased creatinine level, hyponatremia, hypocalcemia, hypoxemia) and two clinical criteria (purpuric rash, stupor, pneumonia, bradycardia, coma, jaundice, gastrointestinal bleeding) – More common in patients with underlying disease or in elderly persons – Disease progression: acute stage is from the second to 14th day of the illness; convalescent stage starts from the 21st day • Diagnosis: • Immunofluorescent antibody: direct immunofluorescence of cutaneous biopsy specimens (during active disease) • Culture Enzyme-linked immunosorbent assay (ELISA): detects antibodies to lipopolysaccharides (LPS) of R conorii • Treatment: tetracyclines together with chloramphenicol and quinolones • Typhus Group • Three main forms of typhus: epidemic typhus; ratflea or endemic typhus, and scrub typhus • Diagnosis • Actual isolation and culture of rickettsiae are difficult • Serologic tests for antibodies • Indirect immunofluorescence assay (IFA) • Enzyme-linked immunosorbent assay (ELISA) • Indirect immunoperoxidase • Weil-Felix test • Polymerase chain reaction (PCR): serum or skin biopsy • Complement fixation (CF) • Treatment: doxycycline, chloramphenicol EPIDEMIC TYPHUS • Caused by R prowazekii • Vector: human body louse (Pediculus humanus corporis) • Humans are the natural reservoir • Incubation period of to 14 days • Clinical • Fever, headache • Maculopapular rash occurs on days to • Begins on the axilla and trunk and spreads peripherally • Can become hemorrhagic with necrosis • Mortality is high in untreated elderly patients • Brill-Zinsser disease: mild reccurence of disease: can occur months, years, or even decades after treatment MURINE TYPHUS (ENDEMIC TYPHUS) • Caused by R typhi • Vectors: rat or cat flea (Xenopsylla cheopis, Ctenocephalides felis) • Incubation of to 18 days • Clinical • Erythematous macular eruption without becoming hemorrhagic or necrotic following fever Scrub Typhus (Tsutsugamushi Fever) • Orientia tsutsugamushi (formerly Rickettsia tsutsugamushi); it has a different cell wall structure and genetic composition than that of the rickettsiae • Vector: trombiculid mite (larval stage of a chigger): Leptotrombidium akamushi and possibly L deliense • Incubation period is 5–20 days • Clinical 334 • • • • • • Chapter 18 BACTERIAL DISEASES Headaches, shaking chills, lymphadenopathy, conjunctival injection, fever Painless papule develops at site of bite, and then a central necrosis results with formation of an eschar Five to eight days after infection, dull red rash on trunk and extending to the extremities Pneumonitis or encephalitis can occur Hepatosplenomegaly Regional lymphadenopathy Ehrlichiosis • Due to gram-negative organisms that resemble Rickettsia • Human monocytic ehrlichioses (HME): Ehrlichia chaffensis • Human granulocytic ehrlichiosis (HGE): E phagocytophilia • Vector: Lone Star tick (Amblyoma americanum) or deer tick (Ixodes persulcatus) • Infects mononuclear cells and granulocytes • Clinical • Rash is rare in ehrlichiosis; however, can develop maculopapular lesions following fever • Rare renal failure and encephalopathy • Lymphadenopathy may be present • Diagnosis: • Histology: characteristic morulae in the cytoplasm of leukocytes • Neutropenia, lymphocytopenia, or thrombocytopenia • Elevated immunoglobulin G (IgG) immunofluorescent antibody (IFA) Ehrlichia titer • Treatment: tetracyclines; chloramphenicol is not effective in ehrlichiosis SEXUALLY TRANSMITTED BACTERIAL INFECTIONS Gonorrhea (Fig 18-13) • Neisseria gonorrhoeae (gram-negative intracellular aerobic diplococcus) • Clinical • Men: urethritis; women: dyspareunia, bleeding or discharge • Neonates: bilateral conjunctivitis (ophthalmia neonatorum) after vaginal delivery from an infected mother • Acute perihepatitis with hepatic capsular adhesions (Fitz-Hugh-Curtis syndrome) • Dissemination: arthritis dermatitis syndrome (1–3% of cases) – Septic arthritis: knee is most common site; polyarthralgia with pain, tenderness FIGURE 18-13 Gonorrhea (Reprinted with permission from Connor DH et al Pathology of Infectious Diseases Stanford, CT: Appleton & Lange; 1997, p 686.) – Rare gonococcal meningitis and endocarditis Skin findings: maculopapular, pustular, necrotic, or vesicular lesions; face, scalp, and mouth are usually spared • Diagnosis: • Culture on chocolate agar • Gram stain • Fluorescein-conjugated monoclonal antibodies, enzyme-linked immunoassays • Treatment: ceftriaxone intramuscular, cefixime, ciprofloxacin • Granuloma Inguinale (Fig 18-14) • Klebsiella granulomatis (gram-negative rod), formerly Calymmatobacterium granulomatosis • Clinical • Four types of skin lesions: – Ulcerovegetative (most commonly seen) ᭡ Painless, beefy red ulcers with clean, friable bases and distinct, raised/rolled margins Autoinoculation is common ᭡ – Nodular ᭡ Pruritic, soft, red nodules that ulcerate at the site of inoculation ᭡ Pseudobubo: nodule appears clinically as a lymph node – Cicatricial ᭡ Dry ulcers that progress into scarring plaques Lymphedema may be present ᭡ • Hypertrophic or verrucous (relatively rare) • Vegetating soft masses 335 SEXUALLY TRANSMITTED BACTERIAL INFECTIONS FIGURE 18-15 Lymphogranuloma venereum FIGURE 18-14 Granuloma inguinale (Reprinted with permission from Connor DH et al Pathology of Infectious Diseases Stanford, CT: Appleton & Lange; 1997, p 567.) (Reprinted with permission from Freedberg IM et al Fitzpatrick’s Dermatology in General Medicine, 6th ed New York: McGraw-Hill; 2003, p 2199.) Immunofluorescent testing with monoclonal antibodies • Treatment: doxycycline; alternative is erythromycin • • Diagnosis: • Culture not possible • Smear or biopsy with Wright, Giemsa or Warthin-Starry (silver) stain: Donovan bodies: intracytoplasmic bipolar staining, safety pin– shaped, inclusion bodies seen in histiocytes • Histology: acanthosis, dermis with histiocytes and plasma cells, large and vacuolated macrophages with intracellular bacilli (i.e., Donovan bodies) • Treatment: doxycycline or trimethoprim/ sulfamethoxazole Lymphogranuloma Venereum (Fig 18-15) • Caused by Chlamydia trachomatis L1, L2 (most common), L3 serotypes • Incubation period of 3–21 days • Clinical • stages: – First stage: small papule usually not seen, lasts week, painless – Second stage: buboes (painful lymph nodes) after to weeks; groove sign: enlargement of the nodes above (inguinal) and below (femoral) the inguinal ligament (poupart’s) – Third stage: fistulas seen more often in women, proctocolitis, results in scarring/chronic lymphatic obstruction (acute rectal syndrome) • Diagnosis: • Complement fixation test with titer of 1:64 • Culture Chancroid (Fig 18-16) • Caused by Haemophilus ducreyi (gram-negative bacillus) • The bacteria secretes a cyto-lethal distending toxin (HdCDT): inhibits cell proliferation and induces cell death • Clinical • Soft chancre • Painful ragged punched-out ulcers, undermined borders, covered by a grayish fibrinous membrane • Lymph node involvement mostly unilateral and can rupture • Bubo: tender, fixed, inguinal lymphadenopathy • Diagnosis • Gram staining: organisms in a “school-of-fish” pattern • Culture • Immunochromatography: monoclonal antibodies to the hemoglobin receptor of H ducreyi, hgbA • Treatment • Azithromycin g PO single dose, ceftriaxone 250 mg IM single dose, erythromycin 500 mg PO qid for days, or ciprofloxacin 500 mg PO bid for days • Buboes should be drained Syphilis • Caused by Treponema pallidum (microaerophilic spirochete) 336 Chapter 18 Early latent: 3 mo) treatment with a regimen of several antibiotics used in combination • Rifampin • Ethambutol • Minocycline • Trimethoprim and sulfamethoxazole • Clarithromycin 342 QUIZ Questions The chief difference between impetigo and ecthyma is: A Epidermal ulceration B Etiological organsims C Involvement of resistant organisms D Systemic distribution of toxin E All of the above Bullous impetigo is caused by local production of a toxin produced by that acts to cleave A Group A Streptococcus, democollins B Group A Streptococcus, desmogleins C Staphylococcus aureus, desmocollins D Staphylococcus aureus, desmogleins E Staphyoloccus epidermidis, hemidesmosomes Cutaneous infections with Group A Streptococcus may lead to A Glomerulonephritis B Rheumatic fever C Scarlet fever D A and C only E A, B, and C When staphyloccal scalded skin syndrome occurs in adults, it is often associated with pre-existing: A Complement deficiencies B Liver failure C Renal insufficiency D Tampon use E All of the above In comparison to ordinary cellulitis, erysipelas is distinguished by _ erythema and lesions, often occurring on the face or lower extremity A Brighter eyrthema, well-demarcated lesions B Brighter erythema, poorly demarcated lesions C Duskier erythema, poorly demarcated lesions D Duskier erythema, well-demarcated lesions E None of the above Wood’s lamp examination of erythrasma often demonstrates a “coral-red” fluorescence due to evolution of _ by the bacteria A Aminolevulonic acid (ALA) B Coproporphyrin III C Protoporphyrin IX D Uroporphyin I E Uroporphyrinogen III Chapter 18 BACTERIAL DISEASES Cutaneous anthrax is not typically _ A Edematous B Fatal C Purulent D B and C E A, B, and C Necrotizing fasciitis is characterized by: A A need for a deep incisional biopsy for diagnosis B Ischemia, thrombosis and tissue necrosis C Pain “out of proportion” to physical findings D Rapid spread E All of the above “Hot-tub folliculitis” is caused by: A Erysipelothrix rusiopathiae B Group A Streptococcus C Pseudomonas aeruginosa D Staphylococcus aureus E Staphylococcus epidermidis 10 Matching exercise: Part A—Match the following diseases with their corresponding etiological organism: A B C D Endemic typhus Epidemic typhus Rickettsial pox Rocky Mountain spotted fever E Scrub typhus R R R R R akari prowasekii rickettsii tsutsugamushi typhi Part B—Match the following histopathologic findings with the corresponding disease: A Donovan bodies B Michaelis-Guttman bodies C Mikulicz cells D Rocha-Lima bodies E Virchow cells (globi) granuloma inguinale leprosy malakoplakia rhinoscleroma verruga peruana Answers A Of the answer choices, the chief difference between impetigo and ecthyma is the depth of involvement, with ecthyma yielding true epidermal ulceration Impetigo also tends to involve young children and perioral locations, while ecthyma is more common in teens and adults and is often situated on the lower extremities D In bullous impetigo, certain forms of Staphylococcus aureus (Phage Group 2) may elaborate a toxin which locally cleaves desmogleins, yielding subcorneal epidermal separation D Cutaneous streptococcal infections may yield both post-streptococcal glomerulonephritis and scarlet fever, but they not yield rheumatic fever 343 REFERENCES C Staphyloccal scalded skin syndrome (SSSS) is caused by the elaboration of toxins by the bacteria that are distributed systemically, and act to cleave desmogleins in the upper aspects of the epidermis yielding desquamation Because the toxin is cleared by the kidneys, adults with pre-existing renal insufficiency are at a greater risk for the disease A In comparision to ordinary cellulitis, erysipelas is distinguished by brighter (more red) erythema and sharp and well-dermarcated lesions Erysiploid often demonstrates a more dusky and purple erythema Bilateral lesions are uncommon in both classic cellulitis and erythema and often suggest the existence of a severe exacerbation of stasis dermatitis B Corynebacterium, like Corynebacterium minutissimum that is involved in erythrasma, produced water-soluble coproporphyrin III, which fluoresces a “coral-red” color when examined using a Wood’s lamp Care must be taken not to test recently washed skin, as this may remove the coproporphyrin resulting in a “false-negative” test A The ancient name of “malignant pustulosis” to describe cutaneous anthrax is somewhat of a misnomer as lesions of cutaneous anthrax are rarely purulent With the exception of potential bioterrorism using a “weaponized” strain, most cases of cutaneous anthrax represent an acquired zoonosis and are not fatal “Edema factor,” a toxin elaborated by the organism, can cause significant localized, regional, and even systemic edema E Necrotizing fasciitis is a medical emergency The infection can result in a large degree of tissue loss and mortality, particularly when it is not diagnosed early Often the first indication is pain out of proportion to physical findings and exceeding that of simple cellulitis Tissue necrosis and hemorrhagic bullae often follow later To make the diagnosis a deep incisional biopsy is needed C Hot-tub folliculitis is a self-limited condition caused by the gram-negative organism, Pseudomonas aeruginosa It most often occurs on the skin underneath swimwear and is a result of inadequate chlorination All the other answer choices are gram-positive organisms 10 Part A: A-5, B-2, C-1, D-3, E-4; Part B: A-1, B-3, C-4, D-5, E-2 REFERENCES Blume JE, Levine EG, Heymann WR: Bacterial Diseases, in Bolognia JL et al Dermatology, London: Mosby; 2003 Chian CA, Arrese JE, Pierard GE: Skin manifestations of Bartonella infections Int J Dermatol 2002;41(8):461–466 Czelusta AJ, Yen-Moore A, Evans TY, Tyring SK: Sexually transmitted diseases J Am Acad Dermatol 1999;41(4):614–623 Freedberg IM et al Fitzpatrick’s Dermatology in General Medicine, 6th Ed New York: McGraw-Hill; 2003 McGinley-Smith DE, Tsao SS: Dermatoses from ticks J Am Acad Dermatol 2002;49(3):363–392 McKee PH: Pathology of the Skin: With Clinical Correlations London: Mosby-Wolfe; 1996 Myers SA, Sexton DJ: Dermatologic manifestations of arthropodborne diseases Infect Dis Clin North Am 1994;8(3):689–712 Sadick NS: Current aspects of bacterial infections of the skin Dermatol Clin 1997;15(2):341–349 This page intentionally left blank ... Krejci-Manwaring CHAPTER 11 CUTANEOUS TUMORS / 17 1 John Cangelosi, Doina Ivan, and Alexander J Lazar Ravi Ubriani CHAPTER 12 CHAPTER ORAL PATHOLOGY / 53 MELANOMA AND NON-MELANOMA SKIN CANCER / 19 3... 19 3 Kamal Busaidy and Asra Ali Sumaira Aasi and Katherine M Cox CHAPTER CHAPTER 13 GENITAL DERMATOLOGY / 71 VASCULAR TUMORS AND MALFORMATIONS / 207 Jennifer Krejci-Manwaring and Nishath Ali Denise... DISORDERS / 14 3 Paradi Mirmirani Jason H Miller and Asra Ali CHAPTER EYE FINDINGS / 17 Brenda Chrastil-Latowsky and Syed Azhar CHAPTER NAIL FINDINGS / 35 CHAPTER 10 DISORDERS OF FAT / 15 9 Asra Ali and