Diagnosis of Carbuncle
Carbuncle Diagnosis: Book Excerpts
Diagnostic Tests for Carbuncle: Online Medical Books
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RASH--DISTRIBUTION:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it focal or diffuse? Focal rashes suggest the dermatophytoses, scabies, actinic dermatitis, herpes zoster, warts, contact dermatitis, erythema nodosum, actinic dermatosis, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, pyoderma, acne vulgaris, herpes simplex, impetigo, and tuberous sclerosis. Diffuse rashes suggest xanthoma, erythema multiforme, psoriasis, lichen planus, eczema, drug eruptions, dermatitis herpetiformis, secondary syphilis, exfoliative dermatitis, and pemphigus. A diffuse rash also may be due to pityriasis rosea and tinea versicolor.
- If diffuse, is it primarily the extremities that are involved? A diffuse rash that involves primarily the extremities would suggest smallpox and erythema multiforme, eczema, milium, lichen planus, and psoriasis.
- If diffuse, does it involve primarily the face and trunk? A diffuse rash that involves primarily the face and trunk suggests chickenpox, typhoid fever, German measles, pityriasis rosea, tinea versicolor, and pemphigus.
- If focal, does it primarily involve the extremities? A focal rash that involves primarily the extremities suggests dermatophytosis, erythema nodosum, contact dermatitis, warts, discoid lupus, actinic dermatosis, scabies, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, and pyoderma.
- If focal, is it primarily involving the face and head? A rash that involves primarily the face and head should suggest acne vulgaris, acne rosacea, seborrheic dermatitis, herpes simplex, actinic dermatosis, carcinoma, impetigo, contact dermatitis, Sturge-Weber syndrome, tuberous sclerosis, and tinea capitis.
- Is it equally distributed to the trunk and extremities? A rash that is equally distributed to the trunk and extremities would suggest herpes zoster, neurofibromatosis, scarlet fever, drug eruptions, dermatitis herpetiformis, secondary syphilis, measles, and exfoliative dermatitis.
DIAGNOSTIC WORKUP
If there are any exudates, a smear and culture for fungi and routine bacteria should be done. Skin scrapings may be examined microscopically with a saline or potassium hydroxide preparation to rule out scabies and fungi. A Wood's lamp examination is very useful in diagnosing various fungi. All isolated lesions should be biopsied.
Diffuse rashes require routine CBC, sedimentation rate, urinalysis, chemistry panel, ANA test, and VDRL test. If there is fever, blood cultures should probably be done. Skin biopsies in consultation with a dermatologist should be done in a timely fashion. Patch testing and intradermal skin testing should be done when appropriate. A dark field examination may be necessary. GI series and barium enemas may be necessary to look for GI neoplasms, Crohn's disease, and ulcerative colitis.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RASH--MORPHOLOGY:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the rash macular or papular? A macular or papular rash would suggest scarlet fever, measles, erythema multiforme, exfoliative dermatitis, pityriasis rosea, eczema, contact dermatitis, secondary syphilis, drug eruption, and actinic dermatoses.
- Is the rash pustular? A pustular rash suggests staphylococcus, scabies, secondary syphilis, acne, folliculitis, and dermatophytosis.
- Is the rash vesicular or bullous? A bullous or vesicular rash would suggest chickenpox, smallpox, dermatitis herpetiformis, contact dermatitis, pemphigus, herpes zoster, bullous impetigo, herpes simplex, dyshidrosis, and nummular eczema.
- Is the rash scaly? A scaly rash suggests ichthyosis, psoriasis, lichen planus, neurodermatitis, dermatophytosis, exfoliative dermatitis, and drug eruptions.
- Are there ulcers? The presence of ulcers in the lesions would suggest basal cell carcinoma, syphilis, lupus erythematosus, diabetic ulcers, ischemic ulcers, pyoderma gangrenosum, and ecthyma.
- Is there fever? The presence of fever suggests scarlet fever, measles, erythema multiforme, exfoliative dermatitis, serum sickness, chickenpox, and smallpox.
DIAGNOSTIC WORKUP
This can be found under Rash--Distribution.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Pruritis without Rash:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Hepatobiliary disorders
–Cholestasis of pregnancy: Pruritus is most severe in third trimester, ceases after delivery
–Primary biliary cirrhosis: Increased anti-mitochondrial antibodies
–Biliary obstruction: Pruritus not a presenting symptom
- Endocrine disorders
–Hypo- and hyperthyroidism
- Hematopoietic disorders
–Polycythemia vera: Pruritus classic after emerging from bath, described as severe and prickling
–Hodgkin's lymphoma: Pruritus may present 5 years before diagnosis; pruritus portends a poor prognosis
–Iron deficiency anemia
-
Chronic renal failure: pruritus begins 6 months after start of dialysis, affects up to 75% of patients during or immediately after dialysis
-
Malignancies: Adenocarcinoma, squamous cell carcinomas
-
HIV: Increasing frequency with disease progression
-
Psychogenic states: May have underlying personality disorder such as OCD
-
Senescence: Elderly pruritus very common
-
Drug reactions
-
Less common etiologies (“zebras”) include multiple myeloma, carcinoid syndrome, Waldenström's macroglobulinemia, parasitic infections (e.g., hookworm, onchocerciasis, ascariasis, trichinosis), hepatitis B and C, diabetes mellitus (results in perianal pruritus)
Workup and Diagnosis
- History and physical examination
–A focused history including past medical history, social history, family history, and sexual history is important
–A complete review of systems may identify underlying disease (e.g., change in bowel habits with colon cancer, cold intolerance with hypothyroidism, right upper quadrant pain with hepatic disease)
–Complete physical examination is necessary including stool exam for occult blood, and Pap smear and pelvic examination
–Include a full body skin exam to confirm that there are no cutaneous rashes or lesions
-
Initial lab tests may include CBC with differential (look for eosinophilia associated with parasites), LFTs (alkaline phosphatase is the best screening test for hepatobiliary disorders), renal function tests, thyroid function tests
-
Rule out internal malignancies (e.g., chest X-ray, mammogram, stool for occult blood)
-
Other labs to consider: HIV test, hepatitis B and C panel, serum iron and ferritin, serum and urine protein electrophoresis, stool for ova and parasites, blind skin biopsy with or without immunofluorescence
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Pruritis with Rash:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Infectious causes
–Fungal infections: Dermatophyte infections (tinea), candidiasis (beefy red color with satellite papules), seborrheic dermatitis (from Pityrosporum, common in hair-bearing areas, with scale)
–Bacterial infections: Erythrasma (from Corynebacterium), frequently in axilla
–Viral infections: Chicken pox (Varicella)
–Insect vectors: Scabies, pediculosis or lice (also present on spouse and other family members), flea bites (typically on legs), mosquito bites (central punctum)
–Mixed infections: Intertrigo (present at skin folds or area of friction)
- Noninfectious causes
–Contact dermatitis (e.g. rhus dermatitis): May be revealed in contact history, linear vesicular lesions with sharp margins
–Atopic dermatitis: Erythematous rash in flexural areas, patient with seasonal allergies and/or asthma
–Eczematous dermatitis: Stasis dermatitis (hyperpigmented legs of patients with vascular disease), lichen simplex chronicus (anxious patient who chronically scratches), dyshidrotic eczema (on hands and feet with scaling, erythema, and minute vesicles and painful fissures), nummular eczema (round scaly lesions on dry skin, common in the winter)
–Pityriasis rosea: Mostly on trunk in “Christmas tree” pattern, begins as single, larger “herald” patch
–Lichen planus: Koebner reaction (lesions occur with trauma, such as linear lesions from scratching), purple, polygonal, pruritic papules
–Psoriasis: Koebner reaction, pink, silvery scaling plaques, extensor surfaces, nail pits
- Less common etiologies (“zebras”) include mycoses fungoides (referred to as Sézary syndrome if erythroderma, lymphadenopathy, and atypical circulating white blood cells are present), dermatitis herpetiformis, miliaria (heat rash)
Workup and Diagnosis
- History and physical examination
–Past medical and family history (e.g., asthma, psoriasis) and exposure history (e.g., poison ivy, oak, or sumac) are important, including whether the lesions are occurring for the first time or are recurrent
–Perform a total body skin exam to evaluate distribution of rash; evaluate especially for rashes on the extensor or flexor surfaces of skin folds, and interdigital spaces
–Note the morphology of the lesion (e.g., macule, papule, pustule, plaque, crust, vesicle, bulla, wheal)
–Note the configuration of the lesion [e.g., linear (Koebner reaction or contact), grouped, annular, geographic]
-
Scrape lesions and perform KOH test if fungal infection is suspected (hyphae visible in dermatophyte infections, and pseudohyphae visible in Candida infections)
-
Wood's lamp test: Erythrasma turns coral red
-
Scrape possible burrow site to identify a mite in scabies
-
Patch testing may be done if allergic contact dermatitis is suspected
-
Punch biopsy may be done to establish a histologic diagnosis (e.g., mycosis fungoides)
-
Anti-gliadin antibodies and/or anti-endomysial antibodies may be found in the serum of patients with dermatitis herpetiformis
-
Consider referral to a dermatologist if diagnosis remains unclear
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
RASH, LOCAL:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis is similar to that of the general rash (see page 446).
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Pustular rash:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Papular rash:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.
Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Folliculitis, furunculosis, and carbunculosis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Confirming diagnosis The obvious skin lesion confirms folliculitis, furunculosis, or carbunculosis. Wound culture shows S. aureus; sensitivity will help guide antibiotic therapy.
In carbunculosis, patient history reveals preexistent furunculosis. A complete blood count may reveal an elevated white blood cell count (leukocytosis).
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Pustular rash:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Papular rash:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have him describe associated signs and symptoms, such as fever, headache, and GI distress.
Next, obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, including any sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vesicles/Bullae/Pustules:
Differential Overview
(Field Guide to Bedside Diagnosis)
Vesicles
❑ Herpes simplex
❑ Contact dermatitis
❑ Varicella/zoster
❑ Dyshidrotic eczema
❑ Scabies
❑ Erythema multiforme
❑ Coxsackievirus
❑ Dermatitis herpetiformis
Bullae
❑ Friction blister
❑ Bullous impetigo
❑ Diabetic bullae
❑ Fixed drug eruption
❑ Frostbite
❑ Porphyria cutanea tarda
❑ Staphylococcal scalded skin syndrome
❑ Toxic epidermal necrolysis
❑ Coma bullae
❑ Pseudoporphyria
❑ Pemphigus vulgaris
❑ Bullous pemphigoid
❑ Variegate porphyria
Pustules
❑ Acne vulgaris
❑ Rosacea
❑ Folliculitis
❑ Furuncle
❑ Candida
❑ Gonococcemia
❑ Pustular psoriasis
❑ Hiradenitis suppurativa
❑ Ecthyma gangrenosum
Diagnostic Approach
Vesicles are less than 5 mm in diameter, and bullae are larger. If bullae, petechiae, purpura, or necrosis are present, look for an “allergen” such as HSV, strep, deep fungal infection, collagen disease (especially lupus), or occult neoplasm.
Erythema multiforme can be differentiated from a drug reaction by a dusky violet color and petechiae at the center of the lesion. A target or iris lesion is also characteristic of erythema multiforme.
Staphylococcal scalded skin syndrome can be differentiated from toxic epidermal necrolysis by superficial blisters and absence of oral lesions.
Multidermatomal or disseminated zoster in a young adult should suggest HIV infection.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Scaling Rash:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Eczema
❑ Atopic dermatitis
❑ Seborrheic dermatitis
❑ Tinea versicolor
❑ Pityriasis rosea
❑ Psoriasis
❑ Contact dermatitis
❑ Tinea corporis
❑ Tinea manuum
❑ Stasis dermatitis
❑ Drugs
❑ Lichen planus
❑ Secondary syphilis
❑ Reiter
❑ Bowen disease
❑ Cutaneous T-cell lymphoma
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Folliculitis, furuncles, and carbuncles:
Diagnosis
(Handbook of Diseases)
The obvious skin lesion confirms folliculitis, furuncles, or carbuncles. Wound culture usually shows S. aureus. In carbuncles, patient history reveals preexistent furuncles. A complete blood count may show an elevated white blood cell count (leukocytosis).
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pustular rash:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Papular rash:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Find out when the rash erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have the patient describe associated signs and symptoms, such as fever, headache, and GI distress.
Obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or a rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Pustular rash:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
Examine the entire skin surface, noting if it's dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Papular rash:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Your first step is to fully evaluate the papular rash: note its color, configuration, and location on the patient's body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.
Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
RASH, LOCAL:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis is similar to that of the general rash
.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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