CONFIRMING DIAGNOSIS Isolation of group 2 S. aureus on cultures of skin lesions confirms the diagnosis. However, skin lesions sometimes appear sterile.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Erythema [Erythroderma]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If erythema isn’t associated with anaphylaxis, obtain a detailed health history. (See Differential diagnosis: Erythema, pages 310 and 311.) Find out how long the patient has had the erythema and where it first began. Has he had any associated pain or itching? Has he recently had a fever, an upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who is now ill. Did he have a recent fall or injury in the erythematous area?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as urticaria, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
Cultural Cue: Dark-skinned patients may have difficulty recognizing erythema; as a result, they may present with associated diseases in a more advanced state.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Stomatitis:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of the oral lesion. Describe the onset: Was it abrupt, suggesting infection; or insidious, suggesting inflammatory or neoplastic origin? Are there associated signs and symptoms? Many oral infections are associated with pain, malaise, and fever. Behçet’s disease has associated ocular and genital lesions, whereas other autoimmune diseases such as systemic lupus erythematosus (SLE) or ulcerative colitis may have systemic symptoms (3). Describe the lesions: Are they painful or painless? Infections? Inflammatory lesions and aphthous ulcers are usually painful (3), whereas premalignant and malignant lesions may be painless (2,4). Are there vesicles or bullae? Pemphigoid and pemphigus can cause bullae or ulcers. HSV starts as vesicular lesions, then ulcerates. Varicella zoster lesions can occur in the mouth (3,5). Did vesicles precede the lesions, suggesting HSV, or was there ulceration without vesicles, suggesting aphthous ulcers (3)? Are the lesions white and will they not wipe off of the mucosa? Leukoplakia, a premalignant lesion, is white and will not wipe off. Any coexisting red component, called erythroplakia, greatly increases the malignant potential of the lesion (2,4). Lichen planus also produces a striated white lesion, usually on the buccal mucosa (3). Where are the lesions? HSV tends to occur on periosteally bound mucosa (gingiva, hard palate), whereas recurrent aphthous ulcers occur on nonperiosteally bound mucosa (buccal, lip, or tongue mucosa) (3). The floor of the mouth under the tongue, the lateral aspects of the tongue, the retromolar regions, and the soft palate are worrisome areas for malignancy to develop (4), but malignancy can occur anywhere.
B. Past medical history. Does the patient have systemic inflammatory conditions such as SLE or lichen planus? Has the patient had the lesions previously? Aphthous ulcers and HSV tend to recur. Does the patient wear dentures making him or her more susceptible to denture stomatitis or angular cheilitis, both caused by Candida species (5)? Are HIV-risk factors present, making oral hairy leukoplakia, Kaposi’s sarcoma, and severe oral candidiasis more likely (5)? Do family members or other close associates have similar symptoms, suggesting enteroviral infections (e.g., herpangina and hand-foot-mouth disease) (Chapter 13.3)? Is the patient on any medications known to cause oral drug-related eruptions? Sulfonamides and many other drugs can cause Stevens–Johnson syndrome, whereas recent cancer chemotherapy can produce severe mucosal inflammation.
C. Social history. Does the patient use alcohol or tobacco, thus increasing the risk for premalignancy or malignancy (2,4)? Has there been exposure to known oral irritants such as foods or spices or potential irritants such as chemicals or new mouth care products? Is the patient sexually active and has there been oral–genital contact? Syphilis and gonorrhea can both occur in the oropharynx.
Physical examination
A. Head, eyes, ears, nose, and throat (HEENT). Based on the history, a focused physical examination of the HEENT is necessary. Look for signs of trauma. Examine the conjunctiva and nasal mucosa for inflammatory changes or ulcerations. Evaluate the patient for coexisting upper respiratory signs and symptoms such as rhinorrhea, sinus tenderness to palpation, and otitis media. Inspect facial skin for vesicles from HSV or varicella-zoster or other lesions such as echymoses, malar rash, or viral exantham. Look for facial asymmetry. Varicella-zoster can cause facial nerve paralysis, called the “Ramsay Hunt syndrome.” Evaluate preauricular, postauricular, and cervical lymph node chains. Finally, evaluate the oral cavity, documenting the size, location, and appearance of the lesion.
B. Additional physical examination. Based on findings from the HEENT examination, additional physical examination might include (a) pulmonary examination for viral pneumonitis or pulmonary findings in autoimmune diseases; (b) abdominal and rectal examination for Crohn’s disease or ulcerative colitis; (c) genitourinary examination for mucosal ulcers in Behçet’s disease and Stevens–Johnson syndrome, and for signs of syphilis or gonorrhea; (d) a general skin examination looking for viral exanthemas, drug eruptions, lichen planus, pemphigus, pemphigoid, and SLE; and (e) a musculoskeletal examination for signs of SLE, Reiter’s syndrome, or other autoimmune diseases (3).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Erythema Multiforme:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Were there any prodromal symptoms?
1. Prodromal symptoms occur in one-third of cases, usually in the form of an upper respiratory illness (3).
2. A prodrome is unusual in EM minor, but fever, malaise, and myalgias can precede the more severe varieties (Chapters 2.6 and 13.6).
B. Characteristics of the rash
1. What was the time course of onset and the duration of lesions?
a. An acute onset with enlargement of papules over 24 to 48 hours is typical of EM. New lesions can develop over 10 days or more with a usual duration of 1 to 6 weeks from onset to healing (3). Be aware of late onset lesions as they may also be a recurrence.
2. Where are the lesions?
a. EM lesions usually start on the hands and feet, including palms and soles, and can spread proximally to become generalized.
b. The mouth and lips are involved up to 99% of the time. More extensive mucosal involvement is seen in the more severe cases. Mouth lesions are usually tender.
c. The rash is symmetric.
3. Skin symptoms
a. Are the lesions painful or pruritic? Oral lesions are usually tender. The patient may complain of itching, swelling, and tenderness of the hands and feet.
C. Recent exposures
1. Has the patient been exposed to any drugs 1 to 3 weeks prior to onset (4)? These most often include sulfonamides, penicillin, anticonvulsants, and nonsteroidal antiinflammatory drugs. Drugs often lead to extensive mucosal erosions with large bullae.
2. Has the patient recently been ill?
a. The percent of EM cases precipitated by herpes simplex virus (HSV) is likely greater than 50% (3). HSV usually presents as EM minor, and it is recurrent in one-third of cases.
b. Another well-documented factor is infection with mycoplasma pneumonia (2). In this case, EM generally presents in bullous form or as Stevens–Johnson syndrome (Chapter 13.8).
c. Other bacterial and viral causes have been suggested, including tuberculosis (TB), β-hemolytic streptococci, staphylococcal infections, and the bacillus Calmette-Guérin vaccine.
d. Other factors such as radiation therapy, collagen vascular diseases, pregnancy, and carcinomas have been implicated.
Physical examination
A. Description of lesions
1. The rash begins as a round erythematous papule, which enlarges up to 1 to 2 cm over 24 to 48 hours. The periphery of the lesion is erythematous and raised or edematous. The center becomes more cyanotic looking and can be white/yellow or gray. This is the pathognomonic “target lesion,” but it may not be present in all cases. If a blister forms in the middle, the term “iris lesion” is more appropriate.
2. Lesions are generally symmetrical, with acral to central spread including extensor surfaces, face, palms, and soles. Mucosal lesions indicate a more severe type; bullae with sloughing in large sheets suggests TEN.
B. Systemic signs
1. Systemic signs are present in the more serious Stevens–Johnson syndrome and TEN.
2. Systemic signs include high fever, involvement of eyes with corneal ulceration, pulmonary findings, widespread cutaneous involvement, or pneumonia, indicating higher morbidity and mortality.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Oral Lesions:
Differential Overview
(Field Guide to Bedside Diagnosis)
Ulceration
❑ Aphthous ulcers
❑ Angular cheilitis
❑ Herpes simplex
❑ Traumatic ulcers
❑ Impetigo
❑ Erythema multiforme
❑ Mucositis
❑ Lichen planus
❑ Squamous cell cancer
❑ Syphilis
❑ Coxsackievirus A
❑ Herpes zoster
❑ Primary HIV
❑ Crohn disease
❑ Behçet syndrome
❑ Acute leukemia
❑ Pemphigoid
Glossitis
❑ Vitamin B12 deficiency
❑ Folate deficiency
❑ Niacin deficiency
❑ Riboflavin deficiency
❑ Leukoplakia
❑ Candida
❑ Geographic tongue
❑ Black hairy tongue
❑ Scarlet fever
❑ Kwashiorkor
❑ Polyarteritis nodosa
Macroglossia
❑ Myxedema
❑ Angioedema
❑ Acromegaly
❑ Amyloidosis
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Source: Field Guide to Bedside Diagnosis, 2007
Patterned Erythema:
Differential Overview
(Field Guide to Bedside Diagnosis)
Figurate
❑ Tinea corporis
❑ Urticaria
❑ Erysipelas
❑ Erythema migrans
❑ Secondary syphilis
❑ Livedo reticularis
❑ Erythema multiforme
❑ Cutaneous larva migrans
❑ Granuloma annulare
❑ Erythema marginatum
Photodistribution
❑ Sunburn
❑ Drugs
❑ Polymorphous light eruption
❑ Systemic lupus erythematosus
❑ Porphyria cutanea tarda
❑ Pellagra
Differentiate from Cellulitis
❑ Insect bite
❑ Acute gout
❑ Deep vein thrombophlebitis
❑ Erythema migrans
❑ Fixed drug eruption
❑ Pyoderma gangrenosa
❑ Sweet syndrome
❑ Necrotizing fasciitis
Diagnostic Approach
Sun-exposed areas of the face, the “V” of the neck (but not under the chin), and the dorsum of the hands and feet are common distributions for photodermatitis.
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Source: Field Guide to Bedside Diagnosis, 2007
Herpes simplex:
Diagnosis
(Handbook of Diseases)
Typical lesions may suggest HVH infection. Confirmation requires isolation of the virus from local lesions and a histologic biopsy. A rise in antibodies and moderate leukocytosis may support the diagnosis.
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Source: Handbook of Diseases, 2003
Stomatitis and other oral infections:
Diagnosis
(Handbook of Diseases)
Physical examination allows diagnosis. A smear of ulcer exudate allows identification of the causative organism.
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Source: Handbook of Diseases, 2003
Staphylococcal scalded skin syndrome:
Diagnosis
(Handbook of Diseases)
Careful observation of the three-stage progression of this disease allows diagnosis. Results of exfoliative cytology and a biopsy aid in the differential diagnosis, ruling out erythema multiforme and drug-induced toxic epidermal necrolysis, both of which are similar to SSSS.
CLINICAL TIP: A blood culture is necessary to rule out sepsis.
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Source: Handbook of Diseases, 2003
Erythema:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If erythema isn’t associated with anaphylaxis, obtain a detailed health history. Find out how long the patient has had the erythema and where it first began. Has he had any associated pain or itching? Has he recently had a fever, upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who is now ill. Did he have a recent fall or injury in the area of the erythema?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
Physical examination
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as hives, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Erythema:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If erythema isn’t associated with anaphylaxis, obtain a detailed health history. Find out how long the patient has had the erythema and where it first began. Has he had any associated pain or itching? Has he recently had a fever, upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who’s now ill. Did he have a recent fall or injury in the area of erythema?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Erythema [Erythroderma]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If erythema isn't associated with anaphylaxis, obtain a detailed health history. Find out how long the patient has had the erythema and where it first began. Has he had associated pain or itching? Has he recently had a fever, upper respiratory tract infection, or joint pain? Does he have a history of skin disease or other illness? Does he or anyone in his family have allergies, asthma, or eczema? Find out if he has been exposed to someone who has had a similar rash or who's now ill. Did he have a recent fall or injury in the area of erythema?
Obtain a complete drug history, including recent immunizations. Ask about food intake and exposure to chemicals.
Begin the physical examination by assessing the extent, distribution, and intensity of erythema. Look for edema and other skin lesions, such as hives, scales, papules, and purpura. Examine the affected area for warmth, and gently palpate it to check for tenderness or crepitus.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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