Since its rise in the early 80s, HIV has sadly become one of the most infamously crippling, hard-to-beat viruses.
Recognition of seborrheic dermatitis is important for the primary care physician, because it may be associated with systemic disease, such as Parkinson's disease and human immunodeficiency virus (HIV) infection. Differential diagnosis includes psoriasis, atopic dermatitis, allergic or irritant contact dermatitis, and dermatophyte (tinea) infections.
Treatment includes medicated shampoos containing zinc pyrithione, selenium sulfide, salicylic acid, coal tar, or ketoconazole in combination with topical corticosteroids. Differential diagnosis includes verruca vulgaris (warts), epidermal nevus, melanocytic nevi, and melanoma.
Differential diagnosis includes erythema multiforme, systemic lupus erythematosus (SLE), bullous pemphigoid, mastocytosis.
Treatment includes elimination of known causes, antihistamines (H1 and H2 blockers), oral corticosteroids for acute flares, and, in refractory cases, immunosuppresants such as sulfasalazine and cyclosporine.
Differential diagnosis includes urticaria, bullous arthropod reaction, drug eruption, and bullous pemphigoid. Differential diagnosis includes tinea versicolor, pityriasis alba, postinflammatory hypopigmentation, and hypopigmented mycosis fungoides. Treatment includes broad-spectrum sunscreens, potent topical corticosteroids, topical calcineurin inhibitors (tacrolimus or pimecrolimus), narrow band ultraviolet (UV) B phototherapy, psoralen with UVA (PUVA) therapy, or total depigmentation for extensive disease. The most common cause of erythema nodosum in the pediatric population is streptococcal pharyngitis. Treatment includes identifying and eliminating known causes, bed rest and elevation of the extremities, aspirin or nonsteroidal anti-inflammatory medications (NSAIDs), colchicine, and supersaturated potassium iodide. Pemphigus vulgaris can develop at any age, but it most commonly occurs in the fourth to sixth decades of life, usually in people of Mediterranean or Jewish ancestry.2 Morbidity and mortality are significant, even with treatment. Differential diagnosis includes bullous pemphigoid, Stevens-Johnson syndrome, and epidermolysis bullosa acquisita.
Treatment includes good wound care for affected skin, systemic corticosteroids, various steroid-sparing immunosuppressants, rituximab, intravenous immunoglobulin (IVIg), and plasmapheresis. Bullous pemphigoid occurs most commonly in the elderly, with an onset between 65 and 75 years of age. Differential diagnosis includes bullous SLE, epidermolysis bullosa acquisita, cicatricial pemphigoid, and dermatitis herpetiformis. Treatment includes topical and systemic corticosteroids, steroid-sparing immunosuppressants, and tetracycline in combination with niacinamide. Treatment includes topical and systemic corticosteroids, steroid-sparing immunosuppressants, colchicine, and plasmapheresis. Differential diagnosis includes pilar or epidermal inclusion cyst, adnexal tumor, neurofibroma, and lipoma.
Differential diagnosis includes allergic or irritant contact dermatitis (especially if bilateral), psoriasis, and dermatophyte (tinea) infection. Acanthosis nigricans can develop following the use of some medications, such as systemic corticosteroids, nicotinic acid, diethylstilbestrol, and isoniazid (INH). Differential diagnosis includes confluent and reticulated papillomatosis of Gougerot and Carteaud and Dowling-Degos disease.
Treatment for type I acanthosis nigricans includes identifying and removing the malignant tumor. Sweet's syndrome can occur with inflammatory bowel disease, bowel bypass syndrome, and pregnancy.
Differential diagnosis includes erythema multiforme, deep fungal infection, pyoderma gangrenosum, and cutaneous metastases. Differential diagnosis includes pemphigus vulgaris, bullous pemphigoid, and erythema multiforme. Treatment includes treatment of the underlying malignancy, systemic corticosteroids, steroid-sparing immunosuppressants, rituximab, and plasmapheresis. Erythema gyratum repens is a rare but very distinctive skin disease characterized by reddened concentric bands in a whorled or woodgrain pattern. Carney complex encompasses LAMB syndrome (lentigines, atrial myxoma, mucocutaneous myxomas, and blue nevi) and NAME syndrome (nevi, atrial myxoma, myxoid neurofibromas, and ephelides), entities known to pediatricians, cardiologists, and dermatologists. Differential diagnosis includes cutis laxa, Ehlers-Danlos syndrome, and perforating calcific elastosis.
Ehlers-Danlos syndrome is a heterogeneous group of connective tissue disorders characterized by joint hyperextensibility, hypermobility, skin and vessel fragility, and fish-mouth scars.
Eleven types of Ehlers-Danlos syndrome have been identified with varying associated features, including mitral valve prolapse, blue sclerae, vascular aneurysm, aortic dissection, hernias, angina, gastrointestinal bleeding (perforation), and peripheral vascular disease.
Sarcoidosis is a multisystem, granulomatous disease of the lungs, bones, central nervous system, lymph nodes, eyes, and skin. Differential diagnosis includes rosacea, trichoepitheliomas, granulomatous syphilis, and granuloma annulare. Treatment includes TNF-α inhibitors, metrotrexate, NSAIDs, and steroid-sparing immunosuppressants.
Lupus erythematosus is an autoimmune photosensitive dermatosis that can be localized or systemic, often with significant overlap.
The cutaneous manifestations of SLE include malar erythema, photosensitivity, oral ulcers, discoid plaques, bullae, purpura, calcinosis cutis, and alopecia.
Differential diagnosis includes diabetic sclerodema, scleromyxedema, and chronic graft-versus-host disease. Treatment includes vasodilating drugs, phototherapy (UVA1) for limited disease, methotrexate, and cyclophosphamide. Reactive arthritis (Reiter's syndrome with conjunctivitis, urethritis, and diarrhea) (Fig. Differential diagnosis includes psoriasis, juvenile plantar dermatoses, rheumatoid arthritis, ankylosing spondylitis, and gout.
Treatment includes topical corticosteroids, cyclosporine, or acitretin for refractory disease.
Erythema chronicum migrans, the hallmark of Lyme disease, reflecting early infection with the tick-borne spirochete Borrelia burgdorferi, develops as a red macule or papule at the site of the tick bite and gradually enlarges to an annular, reddened plaque (Fig. Differential diagnosis includes cellulitis, spider bite, erythema multiforme, and erythema annulare centrifugum. Diagnostic criteria include the aforementioned changes plus elevated creatine kinase or aldolase level, positive Jo-1 antibody, and electromyographic changes. Treatment includes systemic corticosteroids, methotrexate and other steroid-sparing immunosuppressants, and TNF-α inhibitors. Differential diagnosis includes linear IgA dermatosis, bullous pemphigoid, scabies, contact dermatitis, and bullous lupus erythematosus.
Acrodermatitis enteropathica is an inherited or acquired condition characterized by pustules, bullae, scaling in an acral and periorificial distribution, and concomitant zinc deficiency.
Differential diagnosis includes other nutritional deficiencies, such as niacin or biotin deficiency, and necrolytic migratory erythema. Necrolytic migratory erythema (glucagonoma syndrome) is a rare disease characterized by erythematous, scaly plaques on acral, intertriginous, and periorificial areas, in association with an islet cell tumor of the pancreas.
Necrolytic acral erythema, characterized by pruritic keratotic plaques on the upper and lower extremities, is a distinctive finding in hepatitis C infection and can resemble a deficiency dermatosis. Gardner's syndrome is an autosomal dominant cancer syndrome characterized by colonic polyposis, osteomas (maxilla, mandible, skull), scoliosis, epidermoid cysts, and soft-tissue tumors (fibromas, desmoids, lipomas). Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) is an autosomal dominant disorder characterized by numerous telangiectases on the skin and oral mucosa (Fig. Treatment includes estrogen therapy or oral contraceptives in postpubertal women, laser cauterization, selective embolization, and supportive care. Muir-Torre syndrome is a disorder characterized by one or more sebaceous tumors (adenoma, epithelioma, carcinoma) and one or more internal neoplasms, usually colorectal or genitourinary, rarely lymphoma.
Peutz-Jeghers syndrome is an autosomal dominant disease characterized by lentigines on the skin (periorbital region, dorsal surfaces of the fingers and toes) and mucosa (lips, buccal mucosa) and hamartomas of the stomach, small intestine, and colon. Differential diagnosis includes LEOPARD syndrome, Carney complex, and Cronkhite-Canada syndrome.
Treatment includes regular and routine endoscopy and symptomatic treatment for hypogeusia and diarrhea. Pyoderma gangrenosum is a neutrophilic dermatosis characterized by painful ulcers with boggy, undermined edges and a border of gray or purple pigmentation (Fig. Differential diagnosis includes infection, vasculitis, spider bite, and factitious disorder. Treatment includes treatment of underlying disease if applicable, local wound care, systemic and intralesional corticosteroids, cyclosporine, and infliximab.
Nephrogenic systemic fibrosis, also known nephrogenic fibrosing dermopathy, is a recently described disorder that resembles scleroderma.


Treatment includes immunosuppressive agents, phototherapy, topical steroids, retinoids, and photopheresis, all with little benefit. Birt-Hogg-Dubé syndrome is a disorder characterized by multiple fibrofolliculomas and trichodiscomas (skin-colored dermal papules on the face and trunk).
Porphyrias are inherited or acquired disorders of heme biosynthesis and can be erythropoietic, hepatic, or mixed in nature, each associated with a specific enzyme defect in the heme pathway.
Precipitating factors include alcohol ingestion, estrogen administration, certain hepatotoxins (dinitrochlorobenzene, carbon tetrachloride), HIV infection, hemochromatosis, and hepatitis C infection.
Differential diagnosis includes bullous SLE, epidermolysis bullosa acquisita, pseudoporphyria, and variegate porphyria. Pseudoporphyria mimics porphyria cutanea tarda without an enzyme defect; plasma and urinary porphyrins are normal.
By recognizing cutaneous manifestations of systemic diseases, the internist can often determine the appropriate diagnosis and therapy or the need for referral to a dermatologist. Joly P, Benichou J , Lok C, et al: Prediction of survival for patients with bullous pemphigoid. Kury S, Dreno B , Bezieau S, et al: Identification of SLC39A4, a gene involved in acrodermatitis enteropathica. High WA, Ayers RA , Chandler J, et al: Gadolinium is detectable within the tissue of patients with nephrogenic systemic fibrosis. These pictures are shown as "Mosquito Hawk Bites", however, Mosquito Hawks are actually Crane Flies, and they do not bite humans, and they do not eat Mosquitos. If you believe that any content appearing on this site infringes on your copyright, please let us know. The following skull x-ray is from a 3 year old with a history of a head injury 72 hours prior to presentation. Caveat: absence of skull fracture on a plain film does not rule out a significant intracranial injury.
This entry was posted in Advanced EM Cases, EMergucate by Topic, Imaging Case of the Week, Paediatrics by Prathibha. Microchipping a dog is the process of implanting a chip under the dogs skin and registering the keepers details on a national database so that the dogs keeper can be traced.From the 6th April 2016 onwards it will be mandatory that all dogs be microchipped before they are 8 weeks old. All dogs should be vaccinated and have their vaccinations kept up-to-date, this is part of being a responsible dog owner and will be your responsibility.Puppies should receive 2 vaccinations, the first at around 8 to 10 weeks of age and the second, two weeks later at around 10 to 12 weeks of age. Do your research firstGetting a new dog or puppy is a massive commitment, so make sure you have researched the breed fully and have the time and commitment necessary to care for the dog. Confirm that the advertiser is genuineYou should verify this by arranging to visit the dog or puppy at the advertisers home, if they make excuses or try to ask for money or a deposit without seeing the dog, or if the advertiser attempts to deliver the puppies or meet you at any other location than their own home, then please do not agree to this. Can the puppies be viewed with their Mother?The advertiser should ALWAYS let you see the puppies with their mother, and in certain circumstances should let you see the puppies father. Is the Puppy over 8 Weeks of age?Puppies must be at least 8 weeks old and fully weaned before they can leave their mothers.
Check the Health of the Puppy or DogIt can be difficult for the average person to check if a dog or puppy is healthy or not, so if you decide to adopt or buy the puppy, make sure that the seller agrees that you can return them within 48 hours for a full refund after taking the dog or puppy to a Vet of your choice for a health check.
Is the puppy or dog up to date with their vaccinations?Puppies should receive 2 vaccinations, the first at around 8 to 10 weeks of age and the second, two weeks later at around 10 to 12 weeks of age. Ask questions about puppies motherAsk how many litters the mother has had and how old she is, she should be at least 1.5 years old. Have the puppies been socialised ?Make sure that puppies have been socialised from a very early age and are raised in a home environment, have interacted with their litter mates and are used to people, children and general household life.
1) is a common chronic, superficial inflammatory disease of the scalp, face (especially the eyebrows and nasolabial folds), ears, and central chest, affecting 2% to 5% of the population. Patients who have had a cerebrovascular accident (CVA) can develop seborrheic dermatitis on the scalp in a unilateral distribution, corresponding to the affected hemisphere. Alternatively, fluconazole 400 mg (one dose) may be effective in combination with a mild topical corticosteroid. 2), the most common benign cutaneous neoplasms, are warty, age-related hyperkeratotic papules and plaques that appear anywhere on the body, most commonly the trunk. 3), or hives, is most often caused by medication (commonly penicillin or other antibiotics, sulfa drugs, aspirin) or food (shellfish, nuts, chocolate), and less often by infection. Wheals in a fixed location for more than 24 hours suggest the possibility of urticarial vasculitis and warrant a skin biopsy. 4), a cutaneous hypersensitivity reaction, is usually caused by infection (herpes simplex virus or Mycoplasma pneumoniae) and less commonly by drug sensitivity (sulfonamides, barbiturates, antibiotics). 5) is characterized by a focal or generalized distribution of depigmented macules and patches. 6), the most common type of panniculitis, is characterized by painful, erythematous nodules on the shins and occasionally elsewhere. Other infectious causes include tuberculosis, gastrointestinal (GI) infections with Yersinia, Salmonella, or Shigella, and systemic fungal infections.
7) is an uncommon chronic and debilitating blistering disease characterized by painful mucosal erosions and flaccid blisters that become erosive. 8) is the most common bullous disease and is characterized by large, tense subepidermal blisters, which are often pruritic. Prognosis is influenced by age and general condition of the patient, not by extent of disease activity.3 Treatment of older patients in poor health requires caution.
9) is an uncommon bullous disease characterized by skin fragility, milia (small cysts), scarring alopecia, and nail dystrophy. 11) is an uncommon condition characterized by unilateral eczematous plaque of the nipple and areola. Extramammary Paget's disease affects older adults and is often associated with an underlying adnexal (apocrine) carcinoma or an underlying cancer of the genitourinary tract or distal gastrointestinal tract.
Occasionally, acanthosis nigricans is a marker of an underlying adenocarcinoma, especially of the gastrointestinal tract (60% gastric).
Treatment for types II and III includes weight loss and treatment of the underlying endocrine disorder, if applicable.
13), or acute febrile neutrophilic dermatosis, has a strong association with acute myelocytic or myelomonocytic leukemia. Affected patients have papules on the eyelids and extremities that become purpuric and ecchymotic due to increased blood vessel fragility secondary to amyloid infiltration of the vessels. 15), characterized by intractable stomatitis and blisters on the trunk and extremities, has features of pemphigus and erythema multiforme. 16), an acronym for lentigines, electrocardiographic changes, ocular telorism, pulmonary stenosis, abnormal genitalia, retarded growth, and deafness. Recognition of these syndromes is critical because identification and removal of the associated atrial myxomas may be lifesaving. 17) is characterized by yellow papules over redundant skin folds on the neck, abdomen, and groin, giving the skin the appearance of plucked chicken skin.
Ehlers-Danlos syndrome is characterized by abnormalities in collagen biosynthesis, which can affect many organ systems.
Genetic testing for specific mutations has demonstrated redundancy and has reduced Ehlers-Danlos syndrome from eleven to seven types. Asymmetric fusiform swelling of the distal interphalangeal joints (sausage digits), in association with oligoarthritis and tenosynovitis can be seen in up to 70% of PsA patients. 20) is characterized by annular pink to red plaques in a sun-exposed, shawl-like distribution on the chest, back, and arms.
The localized form, known as morphea, begins as erythematous patches that evolve into dusky, hypopigmented, indurated plaques with violaceous borders, usually on the trunk. In adults, dermatomyositis has a strong association with neoplasm, usually an adenocarcinoma of the breast, gastrointestinal tract, or lung.
25) is a chronic, intensely pruritic blistering disease characterized by symmetric grouped vesicles, papules, and wheals on the elbows, knees, scalp, and buttocks. When inherited, acrodermatitis enteropathica results from a mutation in SLC39A, which encodes an intestinal zinc transporter.8 In infants, deficiency can follow breast-feeding, when maternal breast milk contains low levels of zinc.
26) associated with circulating type II cryoglobulins, usually yields palpable purpura on the lower extremities. 27) is characterized by violaceous, flat, polygonal papules, often on the flexor aspects of the wrists, trunk, medial thighs, genitalia, and oral mucosa.
This syndrome results from an inactivating germline mutation of the DNA mismatch repair genes, most often MSH-2. The polyps are usually benign with low malignant potential, but patients have a 10 to 18 times greater lifetime risk of cancer, especially GI malignancies. Nephrogenic systemic fibrosis occurs in patients who have end-stage renal disease and are on dialysis and occasionally in patients with acute renal failure or after kidney transplantation.
Patients have a significantly increased risk of renal oncocytoma and chromophobe renal carcinoma.


Porphyria cutanea tarda, the most common porphyria, is a hepatic porphyria with acquired and sporadic forms (Fig. Manifestations of porphyria cutanea tarda include photosensitivity, skin fragility, bullae and erosions on sun-exposed skin (especially dorsal hands), and hypertrichosis.
Medications (NSAIDs [especially naproxen], furosemide, and tetracycline) are the most common cause of pseudoporphyria. Box 1 outlines the most common cutaneous manifestations of diabetes, arranged by frequency of occurrence (most to least frequent).
From acute febrile neutrophilic dermatosis to neutrophilic disease: Forty years of clinical research. Not being able to see the puppies mother is a sign the puppies have not been bred by the advertiser and possibly imported. But, as the team observed in an HIV-infected lab mouse, when the macrophages’ CB2 receptors were stimulated by THC, they were much better at weakening the virus.
Clinically, the disease is characterized by thin erythematous plaques, often with a fine, greasy scale. Rarely, seborrheic keratoses indicate an underlying adenocarcinoma of the gastrointestinal tract if they appear suddenly in great numbers (sign of Leser-Trélat).
Chronic idiopathic urticaria for which no trigger can be identified often requires further testing such as serum radioallergosorbent testing (RAST) or skin prick-patch testing. Erythema nodosum occurs most commonly in young women, with a peak incidence between 20 and 40 years.1 In addition to the cutaneous findings, patients can have fever, malaise, arthralgias, or arthritis. Less common causes include drug sensitivity (sulfonamides, salicylates, iodides, oral contraceptives or hormone replacement therapy), and a variety of systemic diseases, most often inflammatory bowel disease (Crohn's disease more than ulcerative colitis) and sarcoidosis.
Skin disease typically follows trauma and occurs primarily on the hands, feet, elbows, and knees. Malignant acanthosis nigricans has a sudden onset and more extensive distribution, including the face, palms, and trunk.
Topical treatments including tretinoin, calcipotriol, urea, and salicylic acid may be helpful. Affected patients, usually middle-aged women, have painful erythematous to violaceous plaques on the face, extremities, and trunk. Direct immunofluorescence reveals deposition of IgG intercellularly and at the dermal-epidermal junction. Erythema gyratum repens has a strong association with lung cancer; the association with breast, cervical, and gastrointestinal cancers is less strong. Pseudoxanthoma elasticum represents a defect in elastic fibers, which become brittle and calcified. Patients with vascular (type IV) Ehlers-Danlos syndrome are prone to arterial rupture and have the highest mortality.
Skin disease, affecting 25% to 35% of patients, includes red to purple indurated plaques of the nose (lupus pernio) (Fig. Other presentations include symmetric polyarticular arthritis (15%), distal interphalangeal joint disease with nail damage (16%), arthritis mutilans with erosion of the phalanges (5%), and ankylosing spondylitis (5%). 19), usually localized to the head or neck, is characterized by atrophic, scarring plaques on sun-exposed areas. The systemic or generalized forms are subdivided into CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) and progressive systemic sclerosis. Implicated organisms include Campylobacter, Shigella, Salmonella, Ureaplasma, and Yersinia species. Affected patients can have fever, arthralgia, and myalgia, and, occasionally, Bell's palsy. Biopsy reveals a characteristic neutrophilic infiltrate, and direct immunofluorescence demonstrates deposition of IgA at the dermal-epidermal junction.
Lichen planus also occurs with primary biliary cirrhosis and hepatitis B virus immunization. Recurrent epistaxis is the most common presenting manifestation of the syndrome, affecting approximately 85% to 90% of patients. The ulcers often follow trauma (pathergy) and begin as pustules or nodules that ulcerate and extend centrifugally.9 All body areas may be involved, but the legs are the most common site. Nephrogenic systemic fibrosis is characterized by thick, indurated plaques on the extremities and the trunk. Also, I was drinking the whole time I was there, so I probably oozed what makes one so attractive to bugs. After suffering the injury, he had beenĀ observed in the ED for 4 hours, remained well and was then discharged home. The child underwent a CT scan of the head which confirmed the fracture and did not show any intracranial bleed.
Vitiligo commonly occurs in periorificial areas (mouth, orbits, vagina, anus) or at sites of trauma (hands, elbows, knees). Biopsy reveals characteristic suprabasilar acantholysis and intraepidermal bullae formation.
Immunofluorescence is similar to bullous pemphigoid, with IgG deposition at the dermal-epidermal junction. Skin biopsy reveals swollen, fragmented elastic fibers, and fundoscopic examination reveals angioid streaks in Bruch's membrane. 18), midfacial papules, annular plaques, and plaques or nodules on the trunk and extremities. Presence of anticentromere antibodies correlates with CREST syndrome; SCL-70 antibodies correlate with progressive systemic sclerosis. Affected patients, usually men, often have vesicles and crusted plaques on the penis (circinate balanitis) and erythematous pustules and papules on the palms and soles (keratoderma blennorrhagicum) that can mimic pustular psoriasis. Most patients have an asymptomatic gluten-sensitive enteropathy or, less commonly, thyroid disease.
Oral erosive lichen planus is the most common expression of lichen planus in hepatitis C patients. Telangiectases can involve the lungs, liver, brain, eyes, and gastrointestinal tract; hemorrhage can occur at any site. Fifty percent of patients have underlying rheumatoid arthritis or inflammatory bowel disease or, less often, a paraproteinemia, usually an IgA gammopathy. It is caused by a deficiency in uroporphyrinogen decarboxylase, leading to the accumulation of uroporphyrin in the urine and serum. Direct immunofluorescence reveals IgG and C3 at the dermal-epidermal junction and in vessel walls. Anyway, I'm not sure if these were sand flies or mosquitos or something else, but within a few days I was covered in bites, especially on the feet and lower legs. He has now been brought in by his parents as he’s been irritable since the initial discharge. The disorder is often associated with autoimmune thyroid disease, insulin-dependent diabetes mellitus, pernicious anemia, or Addison's disease.
Direct immunofluorescence reveals a chicken-wire pattern of deposition of immunoglobulin (Ig) G within the epidermis. Direct immunofluorescence reveals a linear deposition of IgG at the dermal-epidermal junction. Associated signs of pseudoxanthoma elasticum include hypertension, peripheral vascular and coronary artery disease, retinal and gastrointestinal hemorrhage, and stroke. More than 50% of patients have sacroiliitis, correlating with the presence of HLA-B27 antigen, but few patients have the classic triad of urethritis, conjunctivitis, and arthritis. Primary endemic areas in the United States are New England, the upper Midwest, and the Pacific Northwest. Approximately 70% of patients have circulating IgA antibodies against the smooth muscle cell endomysium (antiendomysial antibodies), which are somewhat peculiar to dermatitis herpetiformis.
Treatment includes topical and intralesional corticosteroids, topical immunomodulators, and phototherapy. Autopsies have demonstrated that disease is not limited to the skin; visceral organ and muscle fibrosis has been noted.
Erythema nodosum, an acute, painful panniculitis that usually affects the shins, is the most common nonspecific cutaneous manifestation of sarcoidosis.
I couldn't scratch all of the areas that itched fast enough because when I started scratching one bite, another three would be screaming to be scratched.



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