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Derm for the Nurse Practitioner

Derm for the Nurse Practitioner

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Derm for the Nurse Practitioner

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  1. Derm for the Nurse Practitioner Tim Berger, MD Professor of Clinical Dermatology

  2. Case • Painless penile ulcer for 2 weeks • Moderate, non-tender inguinal adenopathy

  3. Diagnosis?

  4. Syphilis Epidemiology • San Francisco has a very high syphilis rate • 60% of syphilis cases are occurring in HIV infected gay men

  5. Primary Syphilis • Clean-based, moist ulceration • Painless, non-tender • Rubbery texture on palpation • Whole lesion moves as an unit • Single or multiple • Non-tender adenopathy 1 week later • Heals spontaneously in 1-4 months with NO scarring

  6. Secondary Syphilis • 80% of patients with secondary syphilis have skin lesions • Early secondary syphilis is more exanthematous, transient, and macular • Later secondary syphilis eruptions are firmer, fixed, papular, pustular, or nodular

  7. Secondary Syphilis (2) • Alopecia (5%): Moth eaten, diffuse • Adenopathy: Generalized, non-tender • Mucous patches (33%): Denuded (tongue), or white/stuck on plaques (other oral areas) • Glomerulonephritis, gastritis/gastric ulcer, rectal ulcers, hepatitis, hearing loss (acute, unilateral), uveitis, neuritis, pulmonary infiltrates, etc.

  8. Secondary Syphilis (3) • Think of syphilis whenever you see a skin rash--It is the great imitator

  9. Fixed Drug Eruption • Reappears at same site with each rechallenge • Individual lesion-iris or target, which blisters, then erodes leaving a shalllow, unilocular, wide ulcer • Oral Mucosa, genitalia (2% of GUD) • Causes: NSAIDs, laxatives, SMZ/TMP

  10. Case • 34 year old gay man with a 2 week history of lethargy, sore throat, fever, pain when swallowing, and rash • VS: Temp 38.6 • Ill appearing

  11. Case • Physical Exam: Pharyngeal erythema without exudate; 3 small ulcerations on the tongue, pharynx; generalized lymphadenopathy (cervical, axillary, groin > 1cm) • Oval plaques with petichiae on the upper chest

  12. Case • Lab: CBC-atypical lymphocytosis • What is the differential diagnosis?

  13. Case • Anticonvulsant hypersensitivity • Streptococcal Pharyngitis • Primary EBV • Primary CMV • Secondary syphilis • Primary HIV infection

  14. Case • Lab: RPR- nonreactive, prozone checked • EBV serology: Negative • HIV Serology: ELISA: Negative • What is your diagnosis?

  15. Case • CD4= 180 • HV Viral load=500,000 • Diagnosis: Primary HIV infection

  16. Primary HIV Infection • Multi-system disease at the time of initial virus replication in the recently infected host (in the first few weeks of infection) • Resembles mononucleosis: rash, oral and genital ulcerations, adenopathy • Skin eruption may precede other findings

  17. Primary HIV Infection • Diagnosis: HIV Viral Load, Helper T cell count; ELISA negative initially

  18. Case • 34 year old healthy male • 2 weeks of recurring blisters on the legs • Mildly itchy

  19. Bullous Impetigo

  20. Bacterial Infections • Pyoderma • Impetigo • Folliculitis • Abscess • Ecthyma • Cellulitis/Necrotizing Fasciitis • Toxic Shock Syndromes

  21. Impetigo

  22. Folliculitis

  23. Ecthyma

  24. Abscess

  25. Cellulitis

  26. Cellulitis with Purpura and Bullae

  27. Erysipelas

  28. Necrotizing Fasciitis

  29. Quiz • The Correct treatment for an abscess is?