Causes of Urticaria

Causes of Urticaria (Diseases Database):

The follow list shows some of the possible medical causes of Urticaria that are listed by the Diseases Database:

• Cilazapril
• Schistosoma haematobium
• Churg-Strauss syndrome
• Familial cold urticaria
• Jellyfish sting
• Dornase alfa
• Cholinergic urticaria
• Ceftriaxone
• Pyrazinamide
• Hepatitis B
• Aspirin
• Propylthiouracil
• Enalapril
• Lymphatic filariasis
• Methionine
• Nalidixic acid
• Ibritumomab tiuxetan
• Penicillin
• Cephalosporins
• CINCA syndrome
• Symptomatic dermatographism
• Schnitzler syndrome
• Muckle-Wells syndrome
• Contact urticaria
• Morphine
• Norfloxacin
• Blood transfusion and complications
• Ancylostoma braziliense
• Mastocytosis
• Zafirlukast
• Snake bite (Viperidae)
• Rifampicin
• Mebendazole
• Paroxysmal cold haemoglobinuria
• Anaphylaxis
• Asparaginase
• Anaphylactoid reactions
• Ancylostoma caninum
• Vasculitis
• Ciprofloxacin
• Angioedema (acquired)
• Strongyloidiasis
• Solar urticaria
• Hymenoptera venom
• C1 esterase inhibitor (C1-INH) deficiency
• Captopril
• Omapatrilat

Source: Diseases Database

Causes of Urticaria: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Urticaria.

Urticaria: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Idiopathic urticaria without angioedema
  –Most common diagnosis in patients with hives
  –Often related to food or drug allergies, bites, or stings
  –25% of patients with one episode will progress to chronic urticaria

• Chronic urticaria
  –Idiopathic in 50% of cases
  –Chronic idiopathic urticaria spontaneously resolves within 2 years in 80% of patients
  –Criterion for chronic urticaria is duration of more than 6 weeks
• Occult infection (e.g., sinusitis, oral infection, cholecystitis, vaginitis, prostatitis, hepatitis, HIV, tinea manus or pedis)
• Malignancy
• Thyroid disease
• Drugs (e.g., radiocontrast media, penicillin, salicylates, benzoates, azo dyes)
  –May result in life-threatening episodes of urticaria and acute angioedema that can lead to anaphylaxis
• Urticaria secondary to physical stimuli [e.g., exercise (cholinergic), vibratory pressure, sun exposure (solar urticaria), cold exposure]
  –Dermographism occurs in 5% of the population; manifests as a physical urticaria that arises in the distribution line of a scratch or rubbed skin area
• Hereditary or acquired deficiency of complement factor C1
  –Generally appears as episodic angioedema in the absence of urticaria
  –Only in the absence of urticaria should hereditary or acquired complement deficiency be considered

• Angioedema-urticaria-eosinophilia syndrome
  –Associated with elevated serum IgE, fever, and fluid retention during an acute attack
• Urticarial vasculitis
  –Presents as urticaria that lasts longer than 12–24 hours
  –Associated with autoimmune disease (e.g., systemic lupus erythematosus)
• Cutaneous mastocytosis/urticaria pigmentosa

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Periorbital Edema: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Conjunctivitis
• Allergy
  –Systemic (e.g., reaction to medication, urticaria/angioedema)
  –Local (e.g., insect bite)
• Contact dermatitis/dermatitis medicamentosa
• Chalazion
  –Zeis or Meibomian gland obstruction of eyelid
• Orbital disease (see “Proptosis/Exophthalmos” entry)
• Preseptal/periorbital cellulitis
• Acute dacryocystitis (infection of the lacrimal ducts)
• Orbital fat herniation through attenuated or dehiscent orbital septum and/or orbicularis oculi muscle (aging changes)
• Herpes simplex/zoster
• Blepharitis/dermatitis
• Trauma/postsurgical (e.g., orbital fracture)
• Dermatomyositis/polymyositis
  –Associated with a heliotropic (violet colored) rash on the upper eyelids
• Chemical, ultraviolet, or thermal burn
• Cardiac failure (generalized edema)
• Renal failure
• Nephrotic syndrome
• Blepharitis/rosacea
• Dacryoadenitis
• Hypothyroidism
  –Associated with fatigue, pretibial edema, and delayed relaxation of reflexes
• Superior vena cava syndrome
• Sebaceous gland carcinoma
• Squamous or basal cell carcinoma
• Discoid lupus
• Ocular cicatricial pemphigoid (symblepharon)

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Peripheral Edema: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Venous insufficiency
  –Caused by incompetent venous valves
  –Skin characteristically has superficial varicose veins associated with a reddish-brown pretibial discoloration (“venous stasis skin changes”)
  –Swelling is typically worse after legs are held in a dependent position and is least noticeable after a night's sleep
• Congestive heart failure
  –Associated with pitting peripheral edema
  –Other signs of heart failure include a third heart sound, cardiomegaly, and hepatomegaly
• Cellulitis
  –Usually unilateral
  –Edematous legs are typically red, warm, and inflamed
  –The patient may exhibit signs of systemic toxicity with fever and leukocytosis
  • Deep venous thrombosis
    –Typically unilateral swelling
    –May exhibit a palpable cord representing a thrombosed vein
    –Homan's sign (pain in the calf with passive dorsiflexion of the foot)
    –Virchow's triad (hypercoagulable states, venous stasis, and vessel injury) are risk factors
  • Cirrhosis
    –Advanced liver disease results in hypoalbuminemia and poor venous return through cirrhotic liver tissue
    –Other stigmata of chronic liver disease include caput medusae, ascites, and spider angiomata
  • Nephrotic syndrome
    –Glomerular damage results in protein loss and decreased oncotic pressure
  • Less common etiologies (“zebras”) include filariasis (lymphatic infection by Wuchereria bancrofti worm), myxedema (seen in patients with severe hypothyroidism), Milroy's disease (congenital lymphedema), chronic lymphedema (e.g., lymphatic damage due to surgery, such as vein harvesting for CABG), and gout

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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)

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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)

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Rash with Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Viral exanthems
  –Leading cause of fever and rash in childhood
  –Most children present with low-grade fevers, viral prodromal symptoms, and a secondary diffuse exanthem that is usually nonspecific and morbilliform
  –Often last only a few days and requires only supportive management
• Drug reactions
  –Account for a large portion of rashes with associated fever
  –Immune complex disease or serum sickness has been reported with many medications
• Meningococcemia
  –Most common under age 1
  –After a brief prodrome; onset is abrupt with spiking fevers, diffuse purpuric lesions, delirium, and death
  –DIC and purpura fulminans with secondary necrosis of digits and limbs can occur

• Rocky Mountain Spotted Fever
  –A fulminant and deadly rickettsial disease transmitted by a tick bite
  –Only 60% of patients are aware of tick bite
  –Characteristic rash starts acrally on wrists and ankles and spreads toward the trunk
  –Initially, pink macules evolve over 10–24 hours into red papules, then purpuric macules and violaceous patches involving most of the body surface area
  –Necrosis and DIC may occur
• Toxic shock syndrome, Staphylococcus aureus, and streptococcal diseases
  –Most cases due to toxin production
  –Rapid onset of fever, hypotension with generalized skin (palms and soles common) and mucous membrane erythema (“erythroderma” in case definition), and subsequent multiorgan failure
  –Palmar/solar desquamation in 1–3 weeks
  –A morbilliform rash and skin “pain” or hyperesthesia is common
  –Nonsurgical and surgical wounds are often the source of infection in the more common nonmenstrual variant of TSS

• Fifth disease
• Measles
• Rubella
• Parvovirus
• Varicella

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Urticaria: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Urticaria
  –Epidemiology: Lifetime incidence 20%; most cases resolve within 48 hours; chronic >6 weeks
  –Pathophysiology: Hypersensitivity reaction: allergens (IgE-mediated, prior sensitization), complement, and other cytokines activate mast cells and basophils to release histamine (also kinins, prostaglandins, serotonin) with plasma extravasation; wheals/hives: dermis edema
  –Triggers: Most cases are idiopathic
  –IgE-mediated: Insects (bees, wasps, scorpions, spiders, jellyfish), foods (eggs, shellfish, tree nuts, peanuts, tomatoes), drugs (penicillins, cephalosporins, NSAIDs, barbiturates, amphetamines, insulin, blood products), pollen, danders, food additives
  –Non-IgE-mediated: Infections (strep, EBV; hepatitis A, B, and C; adenovirus, enterovirus; fleas, mites), drugs (opiates, acetylsalicylic acid, local anesthetics), physical (exercise, cold/heat, UV light, water, pressure), contrast dyes, latex

• Chronic urticaria: Associated with collagen vascular diseases (SLE, cryoglobulinemia), inflammatory bowel disease, malignancy, thyroiditis, hyperthyroidism, Behçet disease, vasculitis
• Angioedema: 50% of urticaria cases; subcutaneous and mucous membrane edema
• Anaphylaxis (IgE-mediated)
  –Most potent foods: Peanuts, fish
  –Mortality: 100–500 deaths/year in U.S.
  –Associated shock has a poor prognosis
• Hereditary angioedema
  –High mortality
  –Most cases are autosomal dominant
  –C1 esterase inhibitor deficiency
  –Recurrent episodes of edema (face, upper airway, extremities)
  –Triggers: Trauma, surgery
  –Unresponsive to epinephrine, antihistamines
• Others: Erythema multiforme, mastocytosis, guttate psoriasis, flushing, cellulitis

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Periorbital Edema: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Periorbital cellulitis
  –Also described as preseptal cellulitis (infection is anterior to the orbital septum and thus does not affect the orbit or globe)
  –Usual pathogens are streptococcal species, Staphylococcus aureus, and Haemophilus influenzae

• Orbital cellulitis
  –Also described as postseptal and affects the preseptal structures as well as the extraocular muscles and the optic nerve
  –Bacterial pathogens are the same as periorbital cellulitis and may reflect direct spread
  –May be accompanied by orbital abscess and may spread via the sinuses to the brain

• Other infections
  –Conjunctivitis
  –Sinusitis
  –Dental abscess
• Allergic reaction
  –Conjunctivitis
  –Urticaria/angioedema
  –Drug reaction
• Local ocular causes
  –Insect bites
  –Contact dermatitis
  –Trauma
  –Foreign body
• Systemic disorders with generalized edema
  –Hypoproteinemia
  –Renal disease
  –Congestive heart failure
• Malignancy
  –Neuroblastomas: Associated with ecchymoses, “raccoon eyes,” and proptosis
  –Leukemia: Associated with fever, fatigue, anemia, bone pain, lymphadenopathy, splenomegaly

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Edema: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Kidney disease (nephrotic syndrome)
  –Insidious onset, periorbital and lower extremity edema, abdominal distension
  –Various types include minimal change disease (MCNS), focal segmental glomerulosclerosis, acute and chronic glomerulonephritis
• Chronic renal failure from any cause may result in impaired fluid excretion
• Liver disease from any cause resulting in impaired production of albumin
• Congestive heart failure (CHF)
• Protein losing enteropathy
  –Menetrier disease (typically CMV), inflammatory bowel disease, neuroblastoma, intestinal lymphangiectasia, trypsinogen deficiency
• Celiac disease
• Sepsis, with capillary leak (movement of fluid out of the blood vessels into the interstitium)
• Hereditary angioneurotic edema
  –Intermittent swelling of extremities
  –Often preceded by trauma
  –Decreased C4 and C1 esterase inhibitor
• Rocky Mountain spotted fever
• Stevens-Johnson syndrome
• Vitamin E deficiency
• Hypothyroidism
• Severe malnutrition
  –Marasmus (calorie deficiency)
  –Kwashiorkor (protein deficiency)
• Zinc deficiency
• Hydrops fetalis
• Impaired lymphatic drainage
  –Milroy disease
  –Meigs syndrome
  –Yellow nail syndrome
  –Lymphedema praecox
• Filariasis (nematode infection resulting in elephantiasis)
• Immobility including placement of body casts and paralysis

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Pustular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acne vulgaris

Pustules typify inflammatory lesions of acne vulgaris, which is accompanied by papules, nodules, cysts, open comedones (blackheads), and closed (whiteheads) comedones. Lesions commonly appear on the face, shoulders, back, and chest. Other findings include pain on pressure, pruritus, and burning. Chronic recurrent lesions produce scars.

Blastomycosis

Blastomycosis is a fungal infection that produces small, painless, nonpruritic macules or papules that can enlarge to well-circumscribed, verrucous, crusted, or ulcerated lesions edged by pustules. Localized infection may cause only one lesion; systemic infection may cause many lesions on the hands, feet, face, and wrists. Blastomycosis also produces signs of pulmonary infection, such as pleuritic chest pain and a dry, hacking or productive cough with occasional hemoptysis.

Folliculitis

Folliculitis is a bacterial infection of hair follicles that produces individual pustules, each pierced by a hair and possibly accompanied by pruritus. “Hot tub” folliculitis produces pustules on areas covered by a bathing suit.

Furunculosis

A furuncle is an acute, deep-seated, red, hot, tender abscess that evolves from a staphylococcal folliculitis. Furuncles usually begin as small, tender red pustules at the base of hair follicles. They’re likely to occur on the face, neck, forearm, groin, axillae, buttocks, and legs or areas that are prone to repeated friction. The pustules usually remain tense for 2 to 4 days and then become fluctuant. Rupture discharges pus and necrotic material. Then pain subsides, but erythema and edema may persist.

Impetigo contagiosa

Impetigo contagiosa, a vesiculopustular eruptive disorder that occurs in nonbullous and bullous forms, is usually caused by streptococci or staphylococci. Vesicles form and break, and a crust forms from the exudate: a thick, yellow crust in streptococcal impetigo and a thin, clear crust in staphylococcal impetigo. Both forms usually produce painless itching.

Pustular miliaria

Pustular miliaria is an anhidrotic disorder that causes pustular lesions that begin as tiny erythematous papulovesicles located at sweat pores. Diffuse erythema may radiate from the lesion. The rash and associated burning and pruritus worsen with sweating.

Pustular psoriasis

Small vesicles form and eventually become pustules in pustular psoriasis. The patient may report pruritus, burning, and pain. Localized pustular psoriasis usually affects the hands and feet. Generalized pustular psoriasis may erupt suddenly in a patient with psoriasis, psoriatic arthritis, or exfoliative psoriasis; although rare, this form of psoriasis can occasionally be fatal.

Rosacea

Rosacea is a chronic hyperemic disorder that commonly produces telangiectasia with acute episodes of pustules, papules, and edema. Characterized by persistent erythema, rosacea may begin as a flush covering the forehead, malar region, nose, and chin. Intermittent episodes gradually become more persistent, and the skin — instead of returning to its normal color — develops varying degrees of erythema.

Scabies

Threadlike channels or burrows under the skin characterize scabies, which can also produce pustules, vesicles, and excoriations. The lesions are a few millimeters long, with a swollen nodule or red papule that contains the itch mite.

Gender Cue: In men, crusted lesions commonly develop on the glans, shaft, and scrotum. In women, lesions may form on the nipples. In both genders, these lesions have a predilection for skin folds. Crusty excoriated lesions also develop on wrists, elbows, axillae, waistline, behind the knees, and ankles. Related pruritus worsens with inactivity and warmth.

Smallpox

(variola major). Initial signs and symptoms include a high fever, malaise, prostration, a severe headache, a backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust and, later, the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Varicella zoster

When immunity to varicella declines, the virus reactivates along a dermatome, producing extremely painful and pruritic vesicles and pustules (herpes zoster, or shingles). Even with resolution of the rash, patients may experience chronic pain (postherpetic neuralgia) that may persist for months.

Other causes

Drugs

Bromides and iodides commonly cause a pustular rash. Other drug causes include corticotropin, corticosteroids, dactinomycin, trimethadione, lithium, phenytoin, phenobarbital, isoniazid, hormonal contraceptives, androgens, and anabolic steroids.

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Urticaria [Hives]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anaphylaxis

Anaphylaxis — an acute reaction — is marked by the rapid eruption of diffuse urticaria and angioedema, with wheals ranging from pinpoint to palm-size or larger. Lesions are usually pruritic and stinging; paresthesia commonly precedes their eruption. Other acute findings include profound anxiety; weakness; diaphoresis; sneezing; shortness of breath; profuse rhinorrhea; nasal congestion; dysphagia; and warm, moist skin.

Hereditary angioedema

With hereditary angioedema — an autosomal dominant disorder — cutaneous involvement is manifested by nonpitting, nonpruritic edema of an extremity or the face. Respiratory mucosal involvement can produce life-threatening acute laryngeal edema.

Lyme disease

Although not diagnostic of Lyme disease — a tick-borne disease — urticaria may result from the characteristic skin lesion (erythema chronicum migrans). Later effects include constant malaise and fatigue, intermittent headache, fever, chills, lymphadenopathy, neurologic and cardiac abnormalities, and arthritis.

Other causes

Drugs

Drugs that can produce urticaria include aspirin, codeine, dextrans, immune serums, insulin, morphine, penicillin, quinine, sulfonamides, and vaccines.

Radiographic contrast medium

Radiographic contrast medium, especially when administered I.V., commonly produces urticaria.

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Edema, generalized: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Angioneurotic edema or angioedema

Recurrent attacks of acute, painless, nonpitting edema involving the skin and mucous membranes — especially those of the respiratory tract, face, neck, lips, larynx, hands, feet, genitalia, or viscera — may be the result of a food or drug allergy or emotional stress or they may be hereditary. Abdominal pain, nausea, vomiting, and diarrhea accompany visceral edema; dyspnea and stridor accompany life-threatening laryngeal edema.

Burns

Edema and associated tissue damage vary with the severity of the burn. Severe generalized edema (4+) may occur within 2 days of a major burn; localized edema may occur with a less severe burn.

Heart failure

Severe, generalized pitting edema — occasionally ana-
sarca — may follow leg edema late in this disorder. The edema may improve with exercise or elevation of the limbs and is typically worse at the end of the day. Among other classic late findings are hemoptysis, cyanosis, marked hepatomegaly, clubbing, crackles, and a ventricular gallop. Typically, the patient has tachypnea, palpitations, hypotension, weight gain despite anorexia, nausea, a slowed mental response, diaphoresis, and pallor. Dyspnea, orthopnea, tachycardia, and fatigue typify left-sided heart failure; jugular vein distention, enlarged liver, and peripheral edema typify right-sided heart failure.

Malnutrition

Anasarca in malnutrition may mask dramatic muscle wasting. Malnutrition also typically causes muscle weakness; lethargy; anorexia; diarrhea; apathy; dry, wrinkled skin; and signs of anemia, such as dizziness and pallor.

Myxedema

With myxedema, which is a severe form of hypothyroidism, generalized nonpitting edema is accompanied by dry, flaky, inelastic, waxy, pale skin; a puffy face; and an upper eyelid droop. Observation also reveals masklike facies, hair loss or coarsening, and psychomotor slowing. Associated findings include hoarseness, weight gain, fatigue, cold intolerance, bradycardia, hypoventilation, constipation, abdominal distention, menorrhagia, impotence, and infertility.

Nephrotic syndrome

Although nephroticsyndrome is characterized by generalized pitting edema, it's initially localized around the eyes. With severe cases, anasarca develops, increasing body weight by up to 50%. Other common signs and symptoms are ascites, anorexia, fatigue, malaise, depression, and pallor.

Pericardial effusion

With pericardial effusion, generalized pitting edema may be most prominent in the arms and legs. It may be accompanied by chest pain, dyspnea, orthopnea, a nonproductive cough, a pericardial friction rub, jugular vein distention, dysphagia, and a fever.

Pericarditis (chronic constructive)

Resembling right-sided heart failure, pericarditisusually begins with pitting edema of the arms and legs that may progress to generalized edema. Other signs and symptoms include ascites, Kussmaul's sign, dyspnea, fatigue, weakness, abdominal distention, and hepatomegaly.

Renal failure

With acute renal failure, generalized pitting edema occurs as a late sign. With chronic renal failure, edema is less likely to become generalized; its severity depends on the degree of fluid overload. Both forms of renal failure cause oliguria, anorexia, nausea and vomiting, drowsiness, confusion, hypertension, dyspnea, crackles, dizziness, and pallor.

Other causes

Drugs

Any drug that causes sodium retention may aggravate or cause generalized edema. Examples include antihypertensives, corticosteroids, androgenic and anabolic steroids, estrogens, and nonsteroidal anti-inflammatory drugs, such as phenylbutazone, ibuprofen, and naproxen.

Treatments

I.V. saline solution infusions and internal feedings may cause sodium and fluid overload, resulting in generalized edema, especially in patients with cardiac or renal disease.

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Edema of the arm: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Angioneurotic edema

Angioneurotic edema is a common reaction that's characterized by the sudden onset of painless, nonpruritic edema affecting the hands, feet, eyelids, lips, face, neck, genitalia, or viscera. Although swelling usually doesn't itch, it may burn and tingle. If edema spreads to the larynx, signs of respiratory distress may occur

Arm trauma

Shortly after a crush injury, severe edema may affect the entire arm. Ecchymoses or superficial bleeding, pain or numbness, and paralysis may occur.

Burns

Twodays or less after injury, arm burns may cause mild to severe edema, pain, and tissue damage.

Envenomation

Envenomation by snakes, aquatic animals, or insects initially may cause edema around the bite or sting that quickly spreads to the entire arm. Pain, erythema, and pruritus at the site are common; paresthesia occurs occasionally. Later, the patient may develop generalized signs and symptoms, such as nausea, vomiting, weakness, muscle cramps, a fever, chills, hypotension, a headache and, in severe cases, dyspnea, seizures, and paralysis.

Superior vena cava syndrome

Bilateral arm edema usually progresses slowly and is accompanied by facial and neck edema. Dilated veins mark these edematous areas. The patient also complains of a headache, vertigo, and vision disturbances.

Thrombophlebitis

Thrombophlebitis, which can result from peripherally inserted central catheters and arm portocaths, may cause arm edema, pain, and warmth. Deep vein thrombophlebitis can also produce cyanosis, a fever, chills, and malaise; superficial thrombophlebitis alsocauses redness, tenderness, and induration along the vein.

Other causes

Treatments

Localized arm edema may result from infiltration of I.V. fluid into the interstitial tissue. A radical or modified radical mastectomy that disrupts lymphatic drainage may cause edema of the entire arm, as can axillary lymph node dissection. Also, radiation therapy for breast cancer may produce arm edema immediately after treatment or months later.

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Edema of the leg: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Burns

Two days or less after injury, leg burns may cause mild to severe edema, pain, and tissue damage.

Cellulitis

Pitting edema and orange peel skin are caused by a streptococcal or staphylococcal infection that most commonly occurs in the lower extremities. Cellulitis is also associated with erythema, warmth, and tenderness in the infected area.

Envenomation

Mild to severe localized edema may develop suddenly at the site of a bite or sting, along with erythema, pain, urticaria, pruritus, and a burning sensation.

Heart failure

Bilateral leg edema is an early sign of right-sided heart failure. Other signs and symptoms include weight gain despite anorexia, nausea, chest tightness, hypotension, pallor, tachypnea, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, a ventricular gallop, and inspiratory crackles. Pitting ankle edema, hepatomegaly, hemoptysis, and cyanosis signal more advanced heart failure.

Leg trauma

Mild to severe localized edema may form around the trauma site.

Osteomyelitis

When osteomyelitis — a bone infection — affects the lower leg, it usually produces localized, mild to moderate edema, which may spread to the adjacent joint. Edema typically follows a fever, localized tenderness, and pain that increases with leg movement.

Thrombophlebitis

Deep and superficial vein thrombosis may cause unilateral mild to moderate edema. Deep vein thrombophlebitis may be asymptomatic or may cause mild to severe pain, warmth, and cyanosis in the affected leg as well as a fever, chills, and malaise. Superficial thrombophlebitis typically causes pain, warmth, redness, tenderness, and induration along the affected vein.

Venous insufficiency (chronic)

Moderate to severe, unilateral or bilateral leg edema occurs in patients with venous insufficiency. Initially, the edema is soft and pitting; later, it becomes hard as tissues thicken. Other signs include darkened skin and painless, easily infected stasis ulcers around the ankle. Venous insufficiency generally occurs in females.

Other causes

Diagnostic tests

Venography is a rare cause of leg edema.

Coronary artery bypass surgery

Unilateral venous insufficiency may follow saphenous vein retrieval.

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Papular rash: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acne vulgaris

With acne vulgaris, rupture of enlarged comedones produces inflamed — and perhaps, painful and pruritic — papules, pustules, nodules, or cysts on the face and sometimes the shoulders, chest, and back.

Anthrax (cutaneous)

Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Cutaneous anthrax occurs when the bacterium enters a cut or abrasion on the skin. The infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, it develops into a vesicle and then a painless ulcer with a characteristic black, necrotic center. Lymphadenopathy, malaise, a headache, or a fever may develop.

Dermatomyositis

Gottron’s papules — flat, violet-colored lesions on the dorsa of the finger joints and the nape of the neck and shoulders — are pathognomonic of dermatomyositis, as is the dusky lilac discoloration of periorbital tissue and lid margins (heliotrope edema). These signs may be accompanied by a transient, erythematous, macular rash in a malar distribution on the face and sometimes on the scalp, forehead, neck, upper torso, and arms. This rash may be preceded by symmetrical muscle soreness and weakness in the pelvis, upper extremities, shoulders, neck and, possibly, the face (polymyositis).

Follicular mucinosis

With follicular mucinosis, perifollicular papules or plaques are accompanied by prominent alopecia.

Fox-Fordyce disease

Fox-Fordyce disease is a chronic disorder that’s marked by pruritic papules on the axillae, pubic area, and areolae associated with apocrine sweat gland inflammation. Sparse hair growth in these areas is also common.

Granuloma annulare

Granuloma annulare is a benign, chronic disorder that produces papules that usually coalesce to form plaques. The papules spread peripherally to form a ring with a normal or slightly depressed center. They usually appear on the feet, legs, hands, or fingers and may be pruritic or asymptomatic.

Human immunodeficiency virus (HIV) infection

Acute infection with the HIV retrovirus typically causes a generalized maculopapular rash. Other signs and symptoms include a fever, malaise, a sore throat, and a headache. Lymphadenopathy and hepatosplenomegaly may also occur. Most patients don’t recall these symptoms of acute infection.

Kaposi’s sarcoma

Kaposi’s sarcoma is characterized by purple or blue papules or macules of vascular origin on the skin, mucous membranes, and viscera. These lesions decrease in size with firm pressure and then return to their original size within 10 to 15 seconds. They may become scaly and ulcerate with bleeding.

Multiple variants of Kaposi’s sarcoma are known; most individuals are immunocompromised in some way, especially those with HIV or acquired immunodeficiency syndrome. Human herpes virus-8 has been strongly implicated as a cofactor in the development of Kaposi’s sarcoma.

Lichen planus

Discrete, flat, angular or polygonal, violet papules, commonly marked with white lines or spots, are characteristic of lichen planus. The papules may be linear or coalesce into plaques and usually appear on the lumbar region, genitalia, ankles, anterior tibiae, and wrists. Lesions usually develop first on the buccal mucosa as a lacy network of white or gray threadlike papules or plaques. Pruritus, distorted fingernails, and atrophic alopecia commonly occur.

Mononucleosis (infectious)

A maculopapular rash that resembles rubella is an early sign of mononucleosis in 10% of patients. The rash is typically preceded by a headache, malaise, and fatigue. It may be accompanied by a sore throat, cervical lymphadenopathy, and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Necrotizing vasculitis

With necrotizing vasculitis, crops of purpuric, but otherwise asymptomatic, papules are typical. Some patients also develop a low-grade fever, a headache, myalgia, arthralgia, and abdominal pain.

Pityriasis rosea

Pityriasis rosea begins with an erythematous “herald patch” — a slightly raised, oval lesion about 2 to 6 cm in diameter that may appear anywhere on the body. A few days to weeks later, yellow to tan or erythematous patches with scaly edges appear on the trunk, arms, and legs, commonly erupting along body cleavage lines in a characteristic “pine tree” pattern. These patches may be asymptomatic or slightly pruritic, are 0.5 to 1 cm in diameter, and typically improve with skin exposure.

Polymorphic light eruption

Abnormal reactions to light may produce papular, vesicular, or nodular rashes on sun-exposed areas. Other symptoms include pruritus, a headache, and malaise.

Psoriasis

Psoriasis is a common chronic disorder that begins with small, erythematous papules on the scalp, chest, elbows, knees, back, buttocks, and genitalia. These papules are sometimes pruritic and painful. Eventually they enlarge and coalesce, forming elevated, red, scaly plaques covered by characteristic silver scales, except in moist areas such as the genitalia. These scales may flake off easily or thicken, covering the plaque. Associated features include pitted fingernails and arthralgia.

Rosacea

Rosacea is a hyperemic disorder characterized by persistent erythema, telangiectasia, and recurrent eruption of papules and pustules on the forehead, malar areas, nose, and chin. Eventually, eruptions occur more frequently and erythema deepens. Rhinophyma may occur in severe cases.

Seborrheic keratosis

With seborrheic keratosis, a cutaneous disorder, benign skin tumors begin as small, yellow-brown papules on the chest, back, or abdomen, eventually enlarging and becoming deeply pigmented. However, in blacks, these papules may remain small and affect only the malar part of the face (dermatosis papulosa nigra).

Smallpox

(variola major). Initial signs and symptoms of smallpox include a high fever, malaise, prostration, a severe headache, a backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Syringoma

With syringoma, adenoma of the sweat glands produces a yellowish or erythematous papular rash on the face (especially the eyelids), neck, and upper chest.

Systemic lupus erythematosus (SLE)

SLE is characterized by a “butterfly rash” of erythematous maculopapules or discoid plaques that appears in a malar distribution across the nose and cheeks. Similar rashes may appear elsewhere, especially on exposed body areas. Other cardinal features include photosensitivity and nondeforming arthritis, especially in the hands, feet, and large joints. Common effects are patchy alopecia, mucous membrane ulceration, a low-grade or spiking fever, chills, lymphadenopathy, anorexia, weight loss, abdominal pain, diarrhea
or constipation, dyspnea, tachycardia, hematuria, a headache, and irritability.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body lice. Initial symptoms include
a headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of chills, a fever, nausea, and vomiting. A maculopapular rash may be present in some cases.

Other causes

Drugs

Transient maculopapular rashes, usually on the trunk, may accompany reactions to many drugs, including antibiotics, such as tetracycline, ampicillin, cephalosporins, and sulfonamides; benzodiazepines, such as diazepam; lithium; phenylbutazone; gold salts; allopurinol; isoniazid; and salicylates.

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Urticaria and angioedema: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Urticaria and angioedema are common allergic reactions that may occur in 20% of the general population. The causes of these reactions include allergy to drugs, foods, insect bites and stings and, occasionally, inhalant allergens (animal dander and cosmetics) that provoke an immunoglobulin (Ig) E-mediated response to protein allergens. However, certain drugs may cause urticaria without an IgE response. When urticaria and angioedema are part of an anaphylactic reaction, they almost always persist long after the systemic response has subsided. This occurs because circulation to the skin is the last to be restored after an allergic reaction, which results in slow histamine reabsorption at the reaction site.

Nonallergic urticaria and angioedema are also related to histamine release. External physical stimuli, such as cold (usually in young adults), heat, water, or sunlight, may also provoke urticaria and angioedema. Dermographism urticaria, which develops after stroking or scratching of the skin, occurs in as much as 20% of the population. Such urticaria develops with varying pressure, usually under tight clothing, and is aggravated by scratching.

Several different mechanisms and underlying disorders may provoke urticaria and angioedema. These include IgE-induced release of mediators from cutaneous mast cells; binding of IgG or IgM to antigen, resulting in complement activation; and such disorders as localized or secondary infections (such as respiratory infection), neoplastic diseases (such as Hodgkin’s disease), connective tissue diseases (such as systemic lupus erythematosus), collagen vascular diseases, and psychogenic diseases.

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Pulmonary edema: Causes
(Professional Guide to Diseases (Eighth Edition))

Pulmonary edema usually results from left-sided heart failure due to arteriosclerotic, hypertensive, cardiomyopathic, or valvular cardiac disease. In such disorders, the compromised left ventricle in unable to maintain adequate cardiac output; increased pressures are transmitted to the left atrium, pulmonary veins, and pulmonary capillary bed. This increased pulmonary capillary hydrostatic force promotes transudation of intravascular fluids into the pulmonary interstitium, decreasing lung compliance and interfering with gas exchange. Other factors that may predispose the patient to pulmonary edema include:

❑ excessive infusion of I.V. fluids

❑ decreased serum colloid osmotic pressure as a result of nephrosis, protein-losing enteropathy, extensive burns, hepatic disease, or nutritional deficiency

❑ impaired lung lymphatic drainage from Hodgkin’s disease or obliterative lymphangitis after radiation

❑ mitral stenosis, which impairs left atrial emptying

❑ pulmonary veno-occlusive disease.

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Pustular rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acne vulgaris

Pustules typify inflammatory lesions of this disorder, which is accompanied by papules, nodules, cysts, open comedones (blackheads) and closed (whiteheads) comedones. Lesions commonly appear on the face, shoulders, back, and chest. Other findings include pain on pressure, pruritus, and burning. Chronic recurrent lesions produce scars.

Blastomycosis

This fungal infection produces small, painless, nonpruritic macules or papules that can enlarge to well-circumscribed, verrucous, crusted, or ulcerated lesions edged by pustules. Localized infection may cause only one lesion; systemic infection may cause many lesions on the hands, feet, face, and wrists. Blastomycosis also produces signs of pulmonary infection, such as pleuritic chest pain and a dry, hacking or productive cough with occasional hemoptysis.

Folliculitis

This bacterial infection of hair follicles produces individual pustules, each pierced by a hair and possibly accompanied by pruritus. “Hot tub” folliculitis produces pustules on areas covered by a bathing suit.

Furunculosis

A furnicle is an acute, deep-seated, red, hot, tender abscess that evolves from a staphylococcus folliculitis. Furuncles usually begin as small, tender red pustules at the base of hair follicles. They’re likely to occur on the face, neck, forearm, groin, axillae, buttocks, and legs; areas that are prone to repeated friction. The pustules usually remain tense for 2 to 4 days and then become fluctuant. Rupture discharges pus and necrotic material. Then pain subsides, but erythema and edema may persist.

Gonococcemia

This disorder produces a rash of scanty, pinpoint erythematous macules that rapidly become vesiculopustular, maculopapular and, frequently, hemorrhagic. Bullae may form. Mature lesions are elevated, with dirty gray necrotic centers and surrounding erythema. The rash appears on the distal part of the arms and legs, usually during the 1st day that other findings, such as fever and joint pain, occur. The rash disappears after 3 to 4 days but may recur with each episode of fever.

Impetigo contagiosa

This vesiculopustular eruptive disorder, which occurs in nonbullous and bullous forms, is usually caused by streptococci or staphylococci. Vesicles form and break, and a crust forms from the exudate: a thick, yellow crust in streptococcal impetigo and a thin, clear crust in staphylococcal impetigo. Both forms usually produce painless itching.

Nummular or annular dermatitis

With this disorder, numerous coinlike (nummular) or ringed (annular) pustular lesions appear, usually on the extensor surfaces of the extremities, posterior trunk, buttocks, and lower legs; a few lesions may appear on the hands. The lesions commonly ooze a purulent exudate, itch severely, and rapidly become crusted and scaly. A few small, scaling patches may remain for some time.

Pustular miliaria

This anhidrotic disorder causes pustular lesions that begin as tiny erythematous papulovesicles located at sweat pores. Diffuse erythema may radiate from the lesion. The rash and associated burning and pruritus worsen with sweating.

Pustular psoriasis

Small vesicles form and eventually become pustules in this disorder. The patient may report pruritus, burning, and pain. Localized pustular psoriasis usually affects the hands and feet. Generalized pustular psoriasis may erupt suddenly in patients with psoriasis, psoriatic arthritis, or exfoliative psoriasis; although rare, this form of psoriasis can occasionally be fatal.

Rosacea

This chronic hyperemic disorder commonly produces telangiectasia with acute episodes of pustules, papules, and edema. Characterized by persistent erythema, rosacea may begin as a flush covering the forehead, malar region, nose, and chin. Intermittent episodes gradually become more persistent, and the skin—instead of returning to its normal color—develops varying degrees of erythema.

Scabies

Threadlike channels or burrows under the skin characterize this disorder, which can also produce pustules, vesicles, and excoriations. The lesions are a few millimeters long, with a swollen nodule or red papule that contains the itch mite.

Gender Cue: In men, crusted lesions commonly develop on the glans, shaft, and scrotum. In women, lesions may form on the nipples. In both sexes these lesions have a predilection for skin folds. Crusty excoriated lesions also develop on wrists, elbows, axillae, waistline, behind the knees and ankles. Related pruritus worsens with inactivity and warmth.

Smallpox (variola major)

Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust and later the scab separates from the skin leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding or secondary infection.

Varicella zoster

When immunity to varicella declines, the virus reactivates along a dermatome, producing extremely painful and pruritic vesicles and pustules (herpes zoster, or shingles). Even with resolution of the rash, patients may experience chronic pain (postherpetic neuralgia) that may persist for months.

Other causes

Drugs

Bromides and iodides commonly cause a pustular rash. Other drug causes include corticotropin, corticosteroids, dactinomycin, trimethadione, lithium, phenytoin, phenobarbital, isoniazid, hormonal contraceptives, androgens, and anabolic steroids.

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Urticaria [Hives]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anaphylaxis

This life-threatening reaction is marked by the rapid eruption of diffuse urticaria and angioedema, with wheals ranging from pinpoint to palm-size or larger. Lesions are usually pruritic and stinging and preceded by paresthesia. Other acute findings include profound anxiety, weakness, diaphoresis, sneezing, shortness of breath, profuse rhinorrhea, nasal congestion, dysphagia, and warm, moist skin.

Lyme disease

Urticaria may result from the characteristic skin lesion (erythema chronicum migrans) produced by this tick-borne disease. Later effects include constant malaise and fatigue, intermittent headache, fever, chills, lymphadenopathy, neurologic and cardiac abnormalities, and arthritis.

Other causes

Drugs

Many drugs can produce urticaria. Among the most common are aspirin, atropine, codeine, dextrans, immune serums, insulin, morphine, penicillin, quinine, sulfonamides, and vaccines. In addition, radiographic contrast media commonly produce urticaria, especially when administered I.V.

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Edema, generalized: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angioneurotic edema or angioedema

Recurrent attacks of acute, painless, nonpitting edema involving the skin and mucous membranes—especially those of the respiratory tract, face, neck, lips, larynx, hands, feet, genitalia, or viscera—may be the result of a food or drug allergy or emotional stress, or they may be hereditary. Abdominal pain, nausea, vomiting, and diarrhea accompany visceral edema; dyspnea and stridor accompany life-threatening laryngeal edema.

Burns

Edema and associated tissue damage vary with the severity of the burn. Severe generalized edema (4+) may occur within 2 days of a major burn; localized edema may occur with a less severe burn.

Cirrhosis

A late sign of chronic cirrhosis, edema usually starts in the legs and thighs and may progress to anasarca. Accompanying signs and symptoms include abdominal pain, anorexia, nausea and vomiting, hepatomegaly, ascites, jaundice, pruritus, bleeding tendencies, musty breath, lethargy, mental changes, and asterixis.

Heart failure

Severe, generalized pitting edema—occasionally anasarca—may follow leg edema late in heart failure. The edema may improve with exercise or elevation of the limbs and is typically worse at the end of the day. Among other classic late findings are hemoptysis, cyanosis, marked hepatomegaly, clubbing, crackles, and a ventricular gallop. Typically, the patient has tachypnea, palpitations, hypotension, weight gain despite anorexia, nausea, slowed mental response, diaphoresis, and pallor. Dyspnea, orthopnea, tachycardia, and fatigue typify left-sided heart failure; jugular vein distention, hepatomegaly, and peripheral edema typify right-sided heart failure.

Malnutrition

Anasarca in this disorder may mask dramatic muscle wasting. Malnutrition also typically causes muscle weakness; lethargy; anorexia; diarrhea; apathy; dry, wrinkled skin; and signs of anemia, such as dizziness and pallor.

Myxedema

In this severe form of hypothyroidism, generalized nonpitting edema is accompanied by dry, flaky, inelastic, waxy, pale skin; a puffy face; and an upper eyelid droop. Observation also reveals masklike facies, hair loss or coarsening, and psychomotor slowing. Associated findings include hoarseness, weight gain, fatigue, cold intolerance, bradycardia, hypoventilation, constipation, abdominal distention, menorrhagia, impotence, and infertility.

Nephrotic syndrome

Although nephrotic syndrome is characterized by generalized pitting edema, the edema is initially localized around the eyes. Anasarca develops in severe cases, increasing body weight by up to 50%. Other common signs and symptoms are ascites, anorexia, fatigue, malaise, depression, and pallor.

Pericardial effusion

In pericardial effusion, generalized pitting edema may be most prominent in the arms and legs. It may be accompanied by chest pain, dyspnea, orthopnea, a nonproductive cough, pericardial friction rub, jugular vein distention, dysphagia, and fever.

Pericarditis (chronic constructive)

Like right-sided heart failure, this disorder usually begins with pitting edema of the arms and legs that may progress to generalized edema. Other signs and symptoms include ascites, Kussmaul’s sign, dyspnea, fatigue, weakness, abdominal distention, and hepatomegaly.

Protein-losing enteropathy

Increased albumin levels lead to progressive generalized pitting edema in this disorder. The patient may also have a mild fever and abdominal pain with bloody diarrhea and steatorrhea.

Renal failure

Generalized pitting edema is a late sign of acute renal failure. In chronic failure, edema is less likely to become generalized; its severity depends on the degree of fluid overload. Both forms of renal failure cause oliguria, anorexia, nausea and vomiting, drowsiness, confusion, hypertension, dyspnea, crackles, dizziness, and pallor.

Septic shock

A late sign of this life-threatening disorder, generalized edema typically develops rapidly. The edema is pitting and moderately severe. Accompanying it may be cool skin, hypotension, oliguria, tachycardia, cyanosis, thirst, anxiety, and signs of respiratory failure.

Other causes

Drugs

Any drug that causes sodium retention may aggravate or cause generalized edema. Examples include antihypertensives, corticosteroids, androgenic and anabolic steroids, estrogens, and nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen.

Treatments

I.V. saline solution infusions and internal feedings may cause sodium and fluid overload, resulting in generalized edema, especially in patients with cardiac or renal disease.

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Edema of the arm: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angioneurotic edema

Angioneurotic edema is a common reaction that’s characterized by sudden onset of painless, nonpruritic edema in the hands, feet, eyelids, lips, face, neck, genitalia, or viscera. Although these swellings usually don’t itch, they may burn and tingle. If edema spreads to the larynx, signs of respiratory distress may occur.

Arm trauma

Shortly after a crush injury, severe edema may affect the entire arm. It may be accompanied by ecchymoses or superficial bleeding, pain or numbness, and paralysis.

Burns

Mild to severe edema, pain, and tissue damage may occur up to 2 days after an arm burn.

Superior vena cava syndrome

Bilateral arm edema usually progresses slowly in this disorder and is accompanied by facial and neck edema. Dilated veins mark these edematous areas. The patient also complains of headache, vertigo, and vision disturbances.

Thrombophlebitis

Thrombophlebitis, which can result from peripherally inserted central catheters or arm portacaths, may cause arm edema, pain, and warmth. Deep vein thrombophlebitis can also produce cyanosis, fever, chills, and malaise; superficial thrombophlebitis also causes redness, tenderness, and induration along the vein.

Other causes

Envenomation

Envenomation by snakes, aquatic animals, or insects initially may cause edema around the bite or sting that quickly spreads to the entire arm. Pain, erythema, and pruritus at the site are common; paresthesia occurs occasionally. Later, the patient may develop generalized signs and symptoms, such as nausea, vomiting, weakness, muscle cramps, fever, chills, hypotension, headache and, in severe cases, dyspnea, seizures, and paralysis.

Treatments

Localized arm edema may result from infiltration of I.V. fluid into the interstitial tissue. A radical or modified radical mastectomy that disrupts lymphatic drainage may cause edema of the entire arm, as can axillary lymph node dissection. Also, radiation therapy for breast cancer may produce arm edema immediately after treatment or months later.

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Edema of the face: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abscess, periodontal

This type of abscess, which usually results from poor oral hygiene, is commonly caused by anaerobic organisms. It can cause edema of the side of the face, pain, warmth, erythema, and a purulent discharge around the affected tooth.

Abscess, peritonsillar

This complication of tonsillitis may cause unilateral facial edema. Other key signs and symptoms include severe throat pain, neck swelling, drooling, cervical adenopathy, fever, chills, and malaise.

Allergic reaction

Facial edema may characterize both a local allergic reaction and anaphylaxis. A local reaction produces facial edema, erythema, and urticaria. In life-threatening anaphylaxis, angioneurotic facial edema may occur with urticaria and flushing. (See Recognizing angioneurotic edema.) Airway edema causes hoarseness, stridor, and bronchospasm with dyspnea and tachypnea. Signs of shock, such as hypotension and cool, clammy skin, may also occur.

Cavernous sinus thrombosis

Cavernous sinus thrombosis is a rare but serious disorder that may begin with unilateral edema that quickly progresses to bilateral edema of the forehead, base of the nose, and eyelids. It may also produce chills, fever, headache, nausea, lethargy, exophthalmos, and eye pain.

Chalazion

A chalazion causes localized swelling and tenderness of the affected eyelid, accompanied by a small red lump on the conjunctival surface.

Conjunctivitis

Conjunctivitis is an inflammation that causes eyelid edema, excessive tearing, and itchy, burning eyes. Inspection reveals a thick purulent discharge, crusty eyelids, and conjunctival injection. Corneal involvement causes photophobia and pain.

Corneal ulcers, fungal

Accompanying red, edematous eyelids in this disorder are conjunctival injection, intense pain, photophobia, and severely impaired visual acuity. Copious amounts of a purulent eye discharge make the eyelids sticky and crusted. The characteristic dense, central ulcer grows slowly, is whitish gray, and is surrounded by progressively clearer rings.

Dacryoadenitis

Severe periorbital swelling characterizes dacryoadenitis, which may also cause conjunctival injection, a purulent discharge, and temporal pain.

Dacryocystitis

Lacrimal sac inflammation causes prominent eyelid edema and constant tearing. In acute cases, pain and tenderness near the tear sac accompany a purulent discharge.

Dermatomyositis

Periorbital edema and a heliotropic rash develop gradually in this rare disease. An itchy, lilac-colored rash appears on the bridge of the nose, cheeks, and forehead. Localized or diffuse erythema, eye pain, and fever may also occur.

Facial burns

Burns may cause extensive edema that impairs respiration. Additional findings include singed nasal hairs, red mucosa, sooty sputum, and signs of respiratory distress such as inspiratory stridor.

Facial trauma

The extent of edema varies with the type of injury. For example, a contusion may cause localized edema, whereas a nasal or maxillary fracture causes more generalized edema. Associated features also depend on the type of injury.

Frontal sinus cancer

This rare form of cancer causes cheek edema on the affected side, reddened skin over the sinus, unilateral nasal bleeding or discharge, and exophthalmos. Pain over the forehead and unilateral hypoesthesia or anesthesia may occur later.

Herpes zoster ophthalmicus (shingles)

In herpes zoster ophthalmicus, edematous and red eyelids are usually accompanied by excessive tearing and a serous discharge. Severe unilateral facial pain may occur several days before vesicles erupt.

Hordeolum (stye)

Typically, a hordeolum produces localized eyelid edema, erythema, and pain.

Malnutrition

Severe malnutrition causes facial edema followed by swelling of the feet and legs. Associated signs and symptoms include muscle atrophy and weakness; anorexia; diarrhea; lethargy; dry, wrinkled skin; sparse, brittle, easily plucked hair; and decreased pulse and respiratory rates.

Melkersson’s syndrome

Facial edema (especially of the lips), facial paralysis, and folds in the tongue are the three characteristic signs of this rare disorder.

Myxedema

Myxedema eventually causes generalized facial edema, waxy dry skin, hair loss or coarsening, and other signs of hypothyroidism.

Nephrotic syndrome

Commonly the first sign of nephrotic syndrome, periorbital edema precedes dependent and abdominal edema. Associated findings include weight gain, nausea, anorexia, lethargy, fatigue, and pallor.

Orbital cellulitis

Sudden onset of periorbital edema marks this inflammatory disorder. It may be accompanied by a unilateral purulent discharge, hyperemia, exophthalmos, conjunctival injection, impaired extraocular movements, fever, and extreme orbital pain.

Osteomyelitis

When osteomyelitis affects the frontal bone, it may cause forehead edema as well as fever, chills, headache, and cool, pallid skin.

Preeclampsia

Edema of the face, hands, and ankles is an early sign of this disorder of pregnancy. Other characteristics include excessive weight gain, severe headache, blurred vision, hypertension, and midepigastric pain.

Rhinitis, allergic

In allergic rhinitis, red and edematous eyelids are accompanied by paroxysmal sneezing, itchy nose and eyes, and profuse, watery rhinorrhea. The patient may also develop nasal congestion, excessive tearing, headache, sinus pain, and sometimes malaise and fever.

Sinusitis

Frontal sinusitis causes edema of the forehead and eyelids. Maxillary sinusitis produces edema in the maxillary area as well as malaise, gingival swelling, and trismus. Both types are also accompanied by facial pain, fever, nasal congestion, a purulent nasal discharge, and red, swollen nasal mucosa.

Superior vena cava syndrome

Superior vena cava syndrome gradually produces facial and neck edema accompanied by thoracic or jugular vein distention. It also causes central nervous system symptoms, such as headache, vision disturbances, and vertigo.

Trachoma

In trachoma, edema affects the eyelid and conjunctiva and is accompanied by eye pain, excessive tearing, photophobia, and eye discharge. Examination reveals an inflamed preauricular node and visible conjunctival follicles.

Trichinosis

This relatively rare infectious disorder causes sudden onset of eyelid edema with fever (102° F to l04° F [38.9° C to 40° C]), conjunctivitis, muscle pain, itching and burning skin, sweating, skin lesions, and delirium.

Other causes

Diagnostic tests

An allergic reaction to contrast media used in radiologic tests may produce facial edema.

Drugs

Long-term use of glucocorticoids may produce facial edema. Any drug that causes an allergic reaction (aspirin, antipyretics, penicillin, and sulfa preparations, for example) may have the same effect.

Herb Alert

Ingestion of the fruit pulp of ginkgo biloba can cause severe erythema and edema and the rapid formation of vesicles. Feverfew and chrysanthemum parthenium can cause swelling of the lips, irritation of the tongue, and mouth ulcers. Licorice may cause facial edema and water retention or bloating, especially if used before menses.

Surgery and transfusion

Facial edema may result from cranial, nasal, or jaw surgery or from a blood transfusion that causes an allergic reaction.

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Edema of the leg: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Burns

Mild to severe edema, pain, and tissue damage may occur up to 2 days after a leg burn.

Cellulitis

Caused by a streptococcal or staphylococcal infection that usually affects the legs, cellulitis produces pitting edema and orange peel skin along with erythema, warmth, and tenderness in the infected area.

Cirrhosis

Cirrhosis commonly causes bilateral edema, which is associated with ascites, jaundice, and abdominal swelling.

Heart failure

Bilateral leg edema is an early sign of right-sided heart failure. Other signs and symptoms include weight gain despite anorexia, nausea, chest tightness, hypotension, pallor, tachypnea, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, a ventricular gallop, and inspiratory crackles. Pitting ankle edema, hepatomegaly, hemoptysis, and cyanosis signal more advanced heart failure.

Hypoproteinemia

Malnourished patients may develop bilateral leg edema secondary to decreased protein and osmotic pressures.

Leg trauma

Mild to severe localized edema may form around the trauma site.

Nephrotic syndrome

Nephrotic syndrome is commonly seen in children and results in bilateral leg edema. It’s associated with polyuria and eyelid swelling.

Osteomyelitis

When this bone infection affects the lower leg, it usually produces localized, mild to moderate edema, which may spread to the adjacent joint. Edema typically follows fever, localized tenderness, and pain that increases with leg movement.

Phlegmasia cerulea dolens

Severe unilateral leg edema and cyanosis may spread to the abdomen and flank in this rare form of venous thrombosis. Other signs and symptoms include pain, cold skin, absent pulse in the affected leg, and signs of shock, such as hypotension and tachycardia.

Rupture of the gastrocnemius muscle

Ruptured gastrocnemius muscle can cause leg edema and often occurs in runners. Pain is usually sudden, and ecchymosis is evident on the ankles.

Rupture of a popliteal (Baker’s) cyst

A ruptured popliteal cyst can cause sudden onset of unilateral calf pain and edema, usually after walking or exercising. This type of cyst is common in patients with arthritis. It can compress vascular structures and cause severe edema and thrombophlebitis.

Thrombophlebitis

Both deep and superficial vein thrombosis may cause unilateral mild to moderate edema. Deep vein thrombophlebitis may be asymptomatic or may cause mild to severe pain, warmth, and cyanosis in the affected leg as well as fever, chills, and malaise. Superficial vein thrombophlebitis typically causes pain, warmth, redness, tenderness, and induration along the affected vein.

Venous insufficiency (chronic)

Moderate to severe unilateral or bilateral leg edema occurs in patients with this disorder, which generally affects females. Initially soft and pitting, the edema later becomes hard as tissues thicken. Other signs include darkened skin and painless, easily infected stasis ulcers around the ankle.

Other causes

Coronary artery bypass surgery

Unilateral venous insufficiency may follow saphenous vein retrieval. Edema often occurs in the affected leg or ankle and usually resolves after 6 to 8 weeks.

Diagnostic tests

Venography is a rare cause of leg edema.

Drugs

Estrogen, hormonal contraceptives, lithium, nonsteroidal anti-inflammatory drugs, vasodilators, and drugs that cause sodium retention can cause bilateral leg edema.

Envenomation

Mild to severe localized edema may develop suddenly at the site of a bite or sting along with erythema, pain, urticaria, pruritus, and a burning sensation.

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Papular rash: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acne vulgaris

With this disorder, rupture of enlarged comedones produces inflamed—and perhaps, painful and pruritic—papules, pustules, nodules, or cysts on the face and sometimes the shoulders, chest, and back.

Anthrax (cutaneous)

Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Cutaneous anthrax occurs when the bacterium enters a cut or abrasion on the skin. The infection begins as a small, painless, or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days it develops into a vesicle and then a painless ulcer with a characteristic black, necrotic center. Lymphadenopathy, malaise, headache, or fever may develop.

Dermatitis (perioral)

This inflammatory disorder causes an erythematous eruption of discrete, tiny papules and pustules on the nasolabial fold, chin, and upper lip area. The lesions may be pruritic and painful.

Dermatomyositis

Gottron’s papules—flat, violet-colored lesions on the dorsa of the finger joints and the nape of the neck and shoulders—are pathognomonic of this disorder, as is the dusky lilac discoloration of periorbital tissue and lid margins (heliotrope edema). These signs may be accompanied by a transient, erythematous, macular rash in a malar distribution on the face and sometimes on the scalp, forehead, neck, upper torso, and arms. This rash may be preceded by symmetrical muscle soreness and weakness in the pelvis, upper extremities, shoulders, neck and, possibly, the face (polymyositis).

Erythema migrans

Transmitted through a tick bite, this systemic disorder is characterized by a papular or macular rash starting from a single lesion (usually on the leg) that spreads at the margins while clearing centrally. The rash commonly appears on the thighs, trunk, or upper arms and is the classic early sign of Lyme disease, but about 25% of patients don’t develop this skin manifestation. It may be accompanied by fever, chills, headache, malaise, nausea, vomiting, fatigue, backache, knee pain, and stiff neck.

Follicular mucinosis

With this cutaneous disorder, perifollicular papules or plaques are accompanied by prominent alopecia.

Fox-Fordyce disease

This chronic disorder is marked by pruritic papules on the axillae, pubic area, and areolae associated with apocrine sweat gland inflammation. Sparse hair growth in these areas is also common.

Gonococcemia

With this chronic STD, sporadic eruption of an erythematous macular rash is characteristic, although fistulas and petechiae may appear. The rash typically affects the distal extremities (palms and soles) and rapidly becomes maculopapular, vesiculopustular and, commonly, hemorrhagic. Bullae may form. The mature lesion is raised; has a gray, necrotic center; and is surrounded by erythema. Typically, it heals in 3 to 4 days. Eruptions are commonly accompanied by fever and joint pain.

Granuloma annulare

This benign, chronic disorder produces papules that usually coalesce to form plaques. The papules spread peripherally to form a ring with a normal or slightly depressed center. They usually appear on the feet, legs, hands, or fingers, and may be pruritic or asymptomatic.

Human immunodeficiency virus (HIV) infection

Acute infection with the HIV retrovirus typically causes a generalized maculopapular rash. Other signs and symptoms include fever, malaise, sore throat, and headache. Lymphadenopathy and hepatosplenomegaly may also occur. Most patients don’t recall these symptoms of acute infection.

Insect bites

Salivary secretions from insect bites—especially ticks, lice, flies, and mosquitoes—may produce an allergic reaction associated with a papular, macular, or petechial rash. The rash is usually accompanied by nonspecific signs and symptoms, such as fever, myalgia, headache, lymphadenopathy, nausea, and vomiting.

Kaposi’s sarcoma

This neoplastic disorder is characterized by purple or blue papules or macules of vascular origin on the skin, mucous membranes, and viscera. These lesions decrease in size with firm pressure and then return to their original size within 10 to 15 seconds. They may become scaly and ulcerate with bleeding.

Multiple variants of Kaposi’s sarcoma are known; most individuals are immunocompromised in some way, especially those with HIV/AIDS (acquired immunodeficiency syndrome). Human herpes virus-8 (HHV-8) has been strongly implicated as a cofactor in the development of Kaposi’s sarcoma.

Leprosy

This chronic infectious disorder produces various skin lesions. Early papular or macular lesions are erythematous, hypopigmented, and symmetrical (with lepromatous leprosy) or asymmetrical (with tuberculoid leprosy). The lesions may spread over the entire skin surface. Later, plaques and nodules form, especially on the ear lobes, nose, eyebrows, and forehead. Associated findings include hypoesthesia or anesthesia, anhidrosis, and dry, scaly skin in affected areas; enlarged, palpable peripheral nerves with severe neuralgia; and muscle atrophy and contractures.

Lichen amyloidosis

This idiopathic cutaneous disorder produces discrete, firm, hemispherical, pruritic papules on the anterior tibiae. Papules may be brown or yellow, smooth or scaly.

Lichen planus

Discrete, flat, angular or polygonal, violet papules, commonly marked with white lines or spots, are characteristic of this disorder. The papules may be linear or coalesce into plaques and usually appear on the lumbar region, genitalia, ankles, anterior tibiae, and wrists. Lesions usually develop first on the buccal mucosa as a lacy network of white or gray threadlike papules or plaques. Pruritus, distorted fingernails, and atrophic alopecia commonly occur.

Monkeypox

Usually preceded 1 to 3 days by a fever, a papular rash is a characteristic sign of monkeypox. The rash is often blisterlike and can follow these stages: vesiculation, postulation, umbilication, and crusting. Frequently beginning on the face and spreading to the trunk and extremities, the rash may be either localized or generalized. Other accompanying symptoms in humans include lymphadenopathy, chills, throat pain, and muscle aches. Most humans recover within 2 to 4 weeks.

Mononucleosis (infectious)

A maculopapular rash that resembles rubella is an early sign of this infection in 10% of patients. The rash is typically preceded by headache, malaise, and fatigue. It may be accompanied by sore throat, cervical lymphadenopathy, and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Mycosis fungoides

Stage I (premycotic stage) of this rare, cutaneous T-cell lymphoma is marked by the eruption of erythematous, pruritic macules on the trunk and extremities. In stage II, these lesions coalesce into pruritic papules and plaques, and nodes become irregular. Stage III is evidenced by large, irregular, brown to red tumors that ulcerate and are painful and itchy.

Necrotizing vasculitis

With this systemic disorder, crops of purpuric, but otherwise asymptomatic, papules are typical. Some patients also develop low-grade fever, headache, myalgia, arthralgia, and abdominal pain.

Parapsoriasis (chronic)

This disorder mimics psoriasis, producing small to moderately sized asymptomatic papules with a thin, adherent scale, primarily on the trunk, hands, and feet.

Pityriasis rosea

This disorder begins with an erythematous “herald patch”—a slightly raised, oval lesion about 2 to 6 cm in diameter that may appear anywhere on the body. A few days to weeks later, yellow to tan or erythematous patches with scaly edges appear on the trunk, arms, and legs, commonly erupting along body cleavage lines in a characteristic “pine tree” pattern. These patches may be asymptomatic or slightly pruritic, are 0.5 to 1 cm in diameter, and typically improve with moderate skin exposure to sunlight. This treatment should be used cautiously, however, to avoid sunburn.

Pityriasis rubra pilaris

This rare chronic disorder initially produces scaling seborrhea on the scalp that spreads to the face and ears. Scaly red patches then develop on the palms and soles; these patches thicken, become keratotic, and may develop painful fissures. Later, follicular papules erupt on the hands and forearms and then spread over wide areas of the trunk, neck, and extremities. These papules coalesce into large, scaly, erythematous plaques. Striated fingernails may appear.

Polymorphic light eruption

Abnormal reactions to light may produce papular, vesicular, or nodular rashes on sun-exposed areas. Other symptoms include pruritus, headache, and malaise.

Psoriasis

This common chronic disorder begins with small, erythematous papules on the scalp, chest, elbows, knees, back, buttocks, and genitalia. These papules are sometimes pruritic and painful. Eventually they enlarge and coalesce, forming elevated, red, scaly plaques covered by characteristic silver scales, except in moist areas such as the genitalia. These scales may flake off easily or thicken, covering the plaque. Associated features include pitted fingernails and arthralgia.

Rat bite fever

A maculopapular or petechial rash develops on the palms and soles several weeks after a bite from an infected rodent. Other findings typically include pain, redness, and swelling at the bite site; tender regional lymph nodes; fever with chills; malaise; headache; and myalgia.

Rosacea

This hyperemic disorder is characterized by persistent erythema, telangiectasia, and recurrent eruption of papules and pustules on the forehead, malar areas, nose, and chin. Eventually, eruptions occur more frequently and erythema deepens. Rhinophyma may occur in severe cases.

Sarcoidosis

This multisystem granulomatous disorder may produce crops of small, erythematous or yellow-brown papules around the eyes and mouth and on the nose, nasal mucosa, and upper back. Associated findings include dyspnea with a nonproductive cough, fatigue, arthralgia, weight loss, lymphadenopathy, vision loss, and dysphagia.

Seborrheic keratosis

With this cutaneous disorder, benign skin tumors begin as small, yellow-brown papules on the chest, back, or abdomen, eventually enlarging and becoming deeply pigmented. However, in blacks, these papules may remain small and affect only the malar part of the face (dermatosis papulosa nigra).

Smallpox (variola major)

Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days the pustules form a crust, and later the scab separates from the skin leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Syphilis

A discrete, reddish brown, mucocutaneous rash and general lymphadenopathy herald the onset of secondary syphilis. The rash may be papular, macular, pustular, or nodular. It typically erupts between rolls of fat on the trunk and proximally on the arms, palms, soles, face, and scalp. Lesions in warm, moist areas enlarge and erode, producing highly contagious, pink or grayish white condylomata lata. The patient may also experience mild headache, malaise, anorexia, weight loss, nausea and vomiting, sore throat, low-grade fever, temporary alopecia, and brittle, pitted nails.

Syringoma

With this disorder, adenoma of the sweat glands produces a yellowish or erythematous papular rash on the face (especially the eyelids), neck, and upper chest.

Systemic lupus erythematosus (SLE)

SLE is characterized by a “butterfly rash” of erythematous maculopapules or discoid plaques that appears in a malar distribution across the nose and cheeks. Similar rashes may appear elsewhere, especially on exposed body areas. Other cardinal features include photosensitivity and nondeforming arthritis, especially in the hands, feet, and large joints. Common effects are patchy alopecia, mucous membrane ulceration, low-grade or spiking fever, chills, lymphadenopathy, anorexia, weight loss, abdominal pain, diarrhea or constipation, dyspnea, tachycardia, hematuria, headache, and irritability.

Typhus

Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of chills, fever, nausea, and vomiting. A maculopapular rash may be present in some cases.

Other causes

Drugs

Transient maculopapular rashes, usually on the trunk, may accompany reactions to many drugs, including antibiotics, such as tetracycline, ampicillin, cephalosporins, and sulfonamides; benzodiazepines such as diazepam; lithium; gold salts; allopurinol; isoniazid; and salicylates.

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Urticaria/Angioedema: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ingestants

❑ Drugs

❑ Inhalants

❑ Hymenoptera venom

❑ Latex sensitivity

❑ Dermatographism

❑ Pressure urticaria

❑ Cholinergic urticaria

❑ Cold urticaria

❑ Solar urticaria

❑ Infection

❑ Urticarial vasculitis

❑ Hereditary angioedema

❑ Mastocytosis

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Edema: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Congestive heart failure

❑ Venous insufficiency

❑ Hypoalbuminemia

❑ Drugs

❑ Cirrhosis

❑ Deep vein thrombosis

❑ Inferior vena cava obstruction

❑ Lymphatic obstruction

❑ Glomerular injury

❑ Idiopathic edema

❑ Myxedema

❑ Lipedema

❑ Toxemia

❑ Cyclical edema

❑ Refeeding

❑ Filariasis

❑ Milroy

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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

Clinical Findings

Eczema  Red, poorly defined patches appear on the neck and flexor surfaces and thicken with excoriations caused by excessive scratching. Coinlike (num-mular) lesions are common on the lower legs.

Atopic dermatitis  Pruritus/scratching lead to eczematous lesions. A personal or family history of atopy (asthma, allergic rhinitis) is elicited. An extra fold of skin below the lower eyelid is a common finding.

Seborrheic dermatitis  Pink-red scaly patches with an indistinct outline develop in the scalp, eyebrows, nasolabial crease, behind the ears, in the ear canal, over the sternum, and in intertriginous areas. New-onset severe seborrheic dermatitis may be the first sign of HIV infection.

Tinea versicolor  A finely scaled macular eruption appears over the trunk. Hypopigmented macules may occur on dark skin; hyperpigmented macules occur on light skin.

Pityriasis rosea  Salmon-pink oval lesions have their long axis following the cleavage lines of the skin. Lesions have a collarette of fine scale around the perimeter. They are distributed on the trunk and proximal extremities, sparing the palms (involved in secondary syphilis). There is usually a herald patch, which is the initial and largest lesion.

Psoriasis  Pink-red sharply demarcated plaques have a silvery micaceous scale. They occur on the elbows, knees, scalp, and gluteal crease. There is often nail dystrophy with pitting, onycholysis, and yellow discoloration. Guttate psoriasis—a widespread eruption of small, scaling lesions—may be brought on by streptococcal infection, lithium, beta-blockers, rapid steroid taper, or acute HIV infection. It spares the face, palms, and soles.

Contact dermatitis  Well-demarcated lesions develop in areas of thin, exposed skin. Lesions are in a localized distribution, reflecting the contact exposure. Common precipitants include poison ivy, nickel jewelry, formaldehyde (in clothing and nail polish), fragrances, perservatives, topical antibiotic cream, rubber, and tanning chemicals. Latex exposure can cause type I hypersensitivity reactions in addition to allergic contact dermatitis.

Tinea corporis  Red annular lesions have an active scaling border with central clearing. The inner thigh is a typical location.

Tinea manuum  One hand is gray-red with scaling within the palmar creases, associated with scaling and nail dystrophy on both feet.

Stasis dermatitis  The lower extremities are edematous, red, and scaling. A brownish discoloration develops due to hemosiderin; it occurs especially over the medial ankle.

Drugs  Pityriasis rosea-like lesions may be seen with beta-blockers, captopril, clonidine, gold, griseofulvin, isotretinoin, metronidazole, and penicillin. Lichenoid eruptions can be produced by gold, antimalarials, thiazides, quinidine, phenothiazines, sulfonylureas, furosemide, methyldopa, griseofulvin, beta-blockers, and captopril.

Lichen planus  Lesions appear as violet-colored, polygonal, and flat-topped papules, traversed by a network of thin gray-white lines (Wickham striae). They occur in the flexor aspects of the wrists, ankles, and glans penis. The oral mucosa also has lacy white plaques or erosions. The plaques are only scaly on the legs.

Secondary syphilis  Scattered red-brown papules with thin scale often involve the palms or soles. Associated findings that assist diagnosis are systemic symptoms such as fever, malaise, and lymphadenopathy; recent (4 to 8 weeks previously) chancre; annular plaques on the face; alopecia; or broad-based and moist condyloma lata.

Reiter  Psoriasiform lesions occur in a patient with arthritis, urethritis, and/or uveitis.

Bowen disease  A single, well-demarcated plaque with variable scale develops in a patient with a known history of arsenic exposure, or exposure manifest as palmar hyperkeratosis.

Cutaneous T-cell lymphoma  Retiform (net-like) psoriatic lesions appear without the typical distribution, with an increase in palpability, and do not respond to topical steroids. The earliest lesions are macular, scaly, and red, admixed with yellow (poikiloderma).

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Urticaria and angioedema: Causes
(Handbook of Diseases)

Urticaria and angioedema are common allergic reactions. Causes include allergy to drugs, foods, insect stings and, occasionally, inhalants, such as animal dander and cosmetics, that provoke an immunoglobulin (Ig) E-mediated response to protein allergens. However, certain drugs may cause urticaria without an IgE response.

When urticaria and angioedema are part of an anaphylactic reaction, they almost always persist long after the systemic response has subsided. This occurs because circulation to the skin is inhibited after an allergic reaction, which results in slow histamine reabsorption at the reaction site. Nonallergic urticaria and angioedema are probably also related to histamine release.

External physical stimuli, such as cold (usually in young adults), heat, water, or sunlight, may provoke urticaria and angioedema. Dermographism urticaria develops with varying pressure, usually under tight clothing, and is aggravated by scratching.  

Several different mechanisms and underlying disorders may provoke urticaria and angioedema. These include IgE-induced release of mediators from cutaneous mast cells; binding of IgG or IgM, resulting in complement activation; localized or secondary infections such as respiratory infection; neoplastic diseases such as Hodgkin’s disease; connective tissue diseases such as systemic lupus erythematosus; collagen vascular diseases; and psychogenic diseases.

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Pulmonary edema: Causes
(Handbook of Diseases)

Pulmonary edema usually results from left-sided heart failure due to arteriosclerotic, hypertensive, cardiomyopathic, or valvular heart disease. In such disorders, the compromised left ventricle requires increased filling pressures to maintain adequate output; these pressures are transmitted to the left atrium, pulmonary veins, and pulmonary capillary bed.

This increased pulmonary capillary hydrostatic force promotes transudation of intravascular fluids into the pulmonary interstitium, decreasing lung compliance and interfering with gas exchange. Other factors that may predispose a person to pulmonary edema include:

❑ infusion of excessive volumes of I.V. fluids

❑ decreased serum colloid