1
|
Gonzales Y Tucker RD, Addepalli A. Fever and Rash. Emerg Med Clin North Am 2024; 42:303-334. [PMID: 38641393 DOI: 10.1016/j.emc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Infectious causes of fever and rash pose a diagnostic challenge for the emergency provider. It is often difficult to discern rashes associated with rapidly progressive and life-threatening infections from benign exanthems, which comprise the majority of rashes seen in the emergency department. Physicians must also consider serious noninfectious causes of fever and rash. A correct diagnosis depends on an exhaustive history and head-to-toe skin examination as most emergent causes of fever and rash remain clinical diagnoses. A provisional diagnosis and immediate treatment with antimicrobials and supportive care are usually required prior to the return of confirmatory laboratory testing.
Collapse
Affiliation(s)
- Richard Diego Gonzales Y Tucker
- Department of Emergency Medicine, University of California San Francisco, Box 0209, 505 Parnassus Avenue, San Francisco, CA 94143, USA; Department of Emergency Medicine, Alameda Health System - Wilma Chan Highland Hospital, 1411 E 31st Street, Oakland, CA 94602, USA.
| | - Aravind Addepalli
- Department of Emergency Medicine, University of California San Francisco, Box 0209, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| |
Collapse
|
2
|
Long B, Liang SY, Carius BM, Chavez S, Gottlieb M, Koyfman A, Brady WJ. Mimics of Monkeypox: Considerations for the emergency medicine clinician. Am J Emerg Med 2023; 65:172-178. [PMID: 36640626 PMCID: PMC9812851 DOI: 10.1016/j.ajem.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Mpox, formerly known as monkeypox, is a public health emergency most commonly presenting with a painful rash and several systemic findings. However, there are several conditions that may mimic its presentation. OBJECTIVE This narrative review provides a focused overview of mpox mimics for emergency clinicians. DISCUSSION Mpox is a global health emergency. The disease is primarily spread through contact, followed by the development of a centrifugally-spread rash that evolves from macules to papules to vesicles to pustules. This is often associated with lymphadenopathy and fever. As the rash is one of the most common presenting signs of the infection, patients mpox may present to the emergency department (ED) for further evaluation. There are a variety of mimics of mpox, including smallpox, varicella, primary and secondary syphilis, acute retroviral syndrome, and genital herpes simplex virus. CONCLUSION Knowledge of mpox and its mimics is vital for emergency clinicians to differentiate these conditions and ensure appropriate diagnosis and management.
Collapse
Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States.
| | - Stephen Y Liang
- Department of Emergency Medicine and Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110, United States of America.
| | - Brandon M Carius
- Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, United States
| | - Summer Chavez
- Department of Health Systems and Population Health Sciences, Tilman J Fertitta Family College of Medicine, University of Houston, Houston, TX 77204, United States
| | - Michael Gottlieb
- Ultrasound Director, Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, United States of America.
| |
Collapse
|
3
|
Knight CL. Physical Examination in Human Immunodeficiency Virus Disease. Med Clin North Am 2022; 106:527-536. [PMID: 35491072 DOI: 10.1016/j.mcna.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Human immunodeficiency virus (HIV)-associated disease is known for its protean manifestations. However, many of the characteristic findings on physical examination are not associated with HIV infection per se but the numerous opportunistic infections (OIs) that are common in patients with advanced HIV disease. Common findings of acute HIV infection include fever, adenopathy, rash, and oral ulcers. Chronic HIV infection is associated with skin, rheumatologic, and neurologic manifestations. OIs also cause skin, oropharyngeal, ocular, and neurologic manifestations. A skilled clinician can often recognize HIV disease based on the combination of these findings.
Collapse
|
4
|
Mass migration and climate change: Dermatologic manifestations. Int J Womens Dermatol 2020; 7:98-106. [PMID: 33537399 PMCID: PMC7838242 DOI: 10.1016/j.ijwd.2020.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 12/26/2022] Open
Abstract
Major changes in climate resulting in mass migrations have unique dermatologic implications for global vulnerable populations. Dermatologic manifestations commonly accompany the infectious and communicable diseases that proliferate in the settings of confinement, crowding, and limited sanitation associated with mass migration. Ectoparasitic infestations abound in refugee camps, and poor nutrition, hygiene, and compromised immunity put refugees at an increased risk for more dangerous infectious diseases carried by these ectoparasites. Climate change also profoundly affects the worldwide distribution of various vector-borne illnesses, thereby leading to the emergence of various communicable diseases in previously nonendemic areas. Natural disasters not only disrupt important lifesaving treatments, but also challenge various infectious disease control measures that are critical in preventing rapid transmission of highly infectious diseases. This article reviews the infectious diseases commonly found in these scenarios and provides an in-depth discussion of important implications for the dermatologist.
Collapse
|
5
|
Organization of the Skin Immune System and Compartmentalized Immune Responses in Infectious Diseases. Clin Microbiol Rev 2019; 32:32/4/e00034-18. [PMID: 31366611 DOI: 10.1128/cmr.00034-18] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The skin is an organ harboring several types of immune cells that participate in innate and adaptive immune responses. The immune system of the skin comprises both skin cells and professional immune cells that together constitute what is designated skin-associated lymphoid tissue (SALT). In this review, I extensively discuss the organization of SALT and the mechanisms involved in its responses to infectious diseases of the skin and mucosa. The nature of these SALT responses, and the cellular mediators involved, often determines the clinical course of such infections. I list and describe the components of innate immunity, such as the roles of the keratinocyte barrier and of inflammatory and natural killer cells. I also examine the mechanisms involved in adaptive immune responses, with emphasis on new cytokine profiles, and the role of cell death phenomena in host-pathogen interactions and control of the immune responses to infectious agents. Finally, I highlight the importance of studying SALT in order to better understand host-pathogen relationships involving the skin and detail future directions in the immunological investigation of this organ, especially in light of recent findings regarding the skin immune system.
Collapse
|
6
|
Abstract
Barrier sites such as the skin play a critical role in immune defense. They must maintain homeostasis with commensals and rapidly detect and limit pathogen invasion. This is accomplished in part through the production of endogenous antimicrobial peptides and proteins, which can be either constitutive or inducible. Here, we focus particularly on the control of innate antiviral proteins and present the basic aspects of their regulation in the skin by interferons (IFNs), IFN-independent immunity, and environmental factors. We also discuss the activity and (dys-)function of antiviral proteins in the context of skin-tropic viruses and highlight the relevance of the innate antiviral pathway as a potential therapeutic avenue for vulnerable patient populations and skin diseases with high risk for virus infections.
Collapse
|
7
|
Lin TY, Yang CJ, Liu CE, Tang HJ, Chen TC, Chen GJ, Hung TC, Lin KY, Cheng CY, Lee YC, Lin SP, Tsai MS, Lee YL, Cheng SH, Hung CC, Wang NC. Clinical features of acute human immunodeficiency virus infection in Taiwan: A multicenter study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 52:700-709. [PMID: 29555411 DOI: 10.1016/j.jmii.2018.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/27/2017] [Accepted: 01/08/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND/PURPOSE Acute HIV infection is characterized by a high concentration of HIV RNA in the plasma and rapid depletion of the CD4 cell count. This multicenter, retrospective observational study aimed to characterize the manifestations of acuteHIV infection in Taiwan. METHODS Between 1 January 2012 and 31 December 2016, all patients aged 20 years or greater who presented with acute HIV infection were included. Demographic and clinical characteristics of the patients at diagnosis were collected. Baseline laboratory assessment included hemogram, CD4 count, plasma HIV RNA load (PVL), serologic markers of syphilis and hepatitis A, B, and C viruses, and serum biochemistry. RESULTS The proportion of acute HIV infection was 6.9% among the patients with newly diagnosed HIV infection during the study period. The most common presenting symptoms of acute HIV infection were fever, fatigue, and myalgia. The median PVL at diagnosis was 5.9 log10 copies/ml, and median CD4 count was 307 cells/mm3. A total of 68 patients (27%) had baseline CD4 count less than 200 cells/mm3. Multiple logistic regression analysis, showed that the baseline CD4 count (OR, 4.02; p = 0.013) and aspartate aminotransaminase levels (OR, 3.49; p = 0.002) were associated with high PVL (>5 log10 copies/ml); and high baseline PVL (OR, 2.64; p = 0.002) was associated with symptomatic acute HIV infection. CONCLUSIONS Manifestations of acute HIV infection are nonspecific and of wide spectrum ranging from fever to severe illness. A higher proportion of patients with initial CD4 counts of 200 cells/mm3 or less during acute HIV infection warrants early, timely diagnosis and treatment to prevent rapid disease progression.
Collapse
Affiliation(s)
- Te-Yu Lin
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chia-Jui Yang
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC; School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chung-Eng Liu
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan, ROC
| | - Hung-Jen Tang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan, ROC
| | - Tun-Chieh Chen
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Department of Internal Medicine, Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Guan-Jhou Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan, ROC
| | - Tung-Che Hung
- Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health Welfare, Taoyuan, Taiwan, ROC
| | - Kuan-Yin Lin
- Department of Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan, ROC
| | - Chien-Yu Cheng
- Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health Welfare, Taoyuan, Taiwan, ROC; School of Public Health, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yi-Chien Lee
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, ROC; Department of Internal Medicine, Catholic Fu-Jen Medical College, New Taipei City, Taiwan, ROC
| | - Shih-Ping Lin
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Mao-Song Tsai
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC; Department of Internal Medicine, Catholic Fu-Jen Medical College, New Taipei City, Taiwan, ROC
| | - Yu-Lin Lee
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan, ROC
| | - Shu-Hsing Cheng
- Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health Welfare, Taoyuan, Taiwan, ROC; School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan, ROC; Department of Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan, ROC
| | - Ning-Chi Wang
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.
| | | |
Collapse
|
8
|
Viral exanthems: An update on laboratory testing of the adult patient. J Am Acad Dermatol 2016; 76:538-550. [PMID: 28413059 DOI: 10.1016/j.jaad.2016.08.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 12/24/2022]
Abstract
Although classic viral exanthems of childhood are well described, they are rarely differentiated in adults. Laboratory techniques for viral identification have advanced without substantial literature to suggest how a dermatologist ought to conduct a cost-effective and diagnostic viral panel. Certain clinical features such as petechiae, vesicles, and dusky macular or morbilliform exanthems point strongly toward a viral exanthem. Differentiation of drug and viral causes of morbilliform eruptions has proven difficult. It is possible that with further diagnostic refinement that unnecessary and fruitless workups of an exanthem and unneeded discontinuation of drugs can be avoided. We review viral exanthems based on clinical features and discuss the available and optimal laboratory techniques to assist the dermatologist in a targeted workup.
Collapse
|
9
|
An Adverse Drug Reaction to Trimethoprim-Sulfamethoxazole Revealing Primary HIV: A Case Report and Literature Review. Case Rep Infect Dis 2015; 2015:691010. [PMID: 26798528 PMCID: PMC4698524 DOI: 10.1155/2015/691010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 11/17/2022] Open
Abstract
Adverse drug reactions (ADRs) to antibiotics complicate the management of any infection, particularly opportunistic infections in advanced HIV as some ADRs are potentiated by HIV. Trimethoprim-sulfamethoxazole (TMP-SMX) causes ADRs in 40-80% of HIV infected individuals, compared to 3-5% in the general population. The incidence and severity of ADRs among HIV infected individuals appear to increase as they progress from latent infection to AIDS. We present a single case report of a 55-year-old African American male found to have an otherwise asymptomatic acute HIV infection who developed an ADR to TMP-SMX, despite having previously tolerating the medication. The proposed mechanisms for the increased incidence of sulfa hypersensitivity reactions among HIV infected individuals focus on either (1) HIV-induced changes in the immune function driven by falling levels of CD4 cells or (2) other HIV-specific factors correlated with rising viral load. To our knowledge this is the first reported case of new sulfa hypersensitivity in primary HIV and may provide clinical evidence to support the correlation between viral load and ADRs to TMP-SMX without a severely diminished CD4 count, though further research is necessary. This case also demonstrates a rare and easily overlooked presentation of HIV that may aid in early diagnosis.
Collapse
|
10
|
Patrício C, Campos S, João A, Serrão V. Nodular mucinosis misdiagnosed as non-responsive secondary syphilis. BMJ Case Rep 2015; 2015:bcr-2015-210285. [PMID: 26311009 DOI: 10.1136/bcr-2015-210285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously healthy 24-year-old man presented with an erythematous, non-pruritic and painless papulonodular skin rash affecting the trunk, upper arms (excluding palms), neck, face, forehead and scalp. He had a penile ulcer for the past 2 weeks, almost healed at the time of observation. The patient tested positive for syphilis and HIV-1; he claimed being negative for HIV 6 months earlier. As the palms were not affected, we performed a skin biopsy for the differential diagnosis between secondary lues and acute HIV seroconversion reaction. Benzathine penicillin (2,400,000 units) was administrated and antiretroviral therapy started. Although the skin biopsy was compatible with secondary syphilis, there was no change in the skin rash 3 weeks after the first penicillin administration. Another 2 doses of penicillin were given but 4 weeks later the rash persisted. A second biopsy revealed a mucinous skin infiltration, compatible with nodular mucinosis.
Collapse
Affiliation(s)
- Catarina Patrício
- Department of Internal Medicine, Hospital de Santo António dos Capuchos, Lisboa, Portugal
| | - Sara Campos
- Department of Dermatology, Hospital de Santo António dos Capuchos, Lisboa, Portugal
| | - Alexandre João
- Department of Dermatology, Hospital de Santo António dos Capuchos, Lisboa, Portugal
| | - Vasco Serrão
- Department of Dermatology, Hospital de Santo António dos Capuchos, Lisboa, Portugal
| |
Collapse
|
11
|
Udassi S, Sun KM, Giordano BP. Acute HIV Infection in an Adolescent. J Pediatr Health Care 2015; 29:371-4. [PMID: 25218606 DOI: 10.1016/j.pedhc.2014.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 06/30/2014] [Accepted: 07/01/2014] [Indexed: 11/26/2022]
|
12
|
Abstract
The clinical spectrum of acute human immunodeficiency virus (HIV) infection, a common clinical syndrome, may range from asymptomatic to a severe illness. The purpose of this review is to increase awareness of this syndrome, which is rarely suspected and often missed in clinical care settings, and provide an informative reference for primary care providers. The diagnosis of acute HIV infection is important for both patient care and public health concerns. In this article, the epidemiology, pathophysiology, clinical presentation, diagnosis and treatment of acute HIV infection are reviewed.
Collapse
|
13
|
Self WH. Acute HIV Infection: Diagnosis and Management in the Emergency Department. Emerg Med Clin North Am 2010; 28:381-92, Table of Contents. [DOI: 10.1016/j.emc.2010.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
14
|
Hurt C, Tammaro D. Diagnostic evaluation of mononucleosis-like illnesses. Am J Med 2007; 120:911.e1-8. [PMID: 17904463 DOI: 10.1016/j.amjmed.2006.12.011] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 11/29/2006] [Accepted: 12/01/2006] [Indexed: 11/26/2022]
Abstract
Clinicians face a diagnostic challenge when a patient with the classic fever, pharyngitis, and lymphadenopathy triad of infectious mononucleosis has a negative "spot" heterophile antibody test. This screening test, although commonly considered sensitive for the presence of Epstein-Barr virus (EBV) infection, may be negative early after infection. A growing number of pathogens have been reported to cause heterophile-negative mononucleosis-like illnesses, including cytomegalovirus (CMV), human herpesvirus 6 (HHV-6), human immunodeficiency virus (HIV), adenovirus, herpes simplex virus (HSV), Streptococcus pyogenes, and Toxoplasma gondii. Other infectious and noninfectious disorders also may present in ways that mimic mononucleosis, but fail to generate EBV's archetypal triad of clinical findings. A systematic approach to the diagnosis of mononucleosis-like illnesses ensures that conditions warranting specific therapy are distinguished from others requiring only supportive care.
Collapse
Affiliation(s)
- Christopher Hurt
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | | |
Collapse
|
15
|
Murali MR, Mackool BT, Muse VV, Zembowicz A, Ferry JA. Case records of the Massachusetts General Hospital. Case 25-2007. A 60-year-old man with fever, odynophagia, weight loss, and rash. N Engl J Med 2007; 357:692-701. [PMID: 17699820 DOI: 10.1056/nejmcpc079019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|