Skin Diseases

In recent years, the role of the immunesystem in the pathogenesis of psoriasishas been extensively delineated. Thisresearch has spawned a new classof medications that target specific immunefactors and hold great promiseas psoriasis therapies. The Table highlightsthe significant features of 4 ofthese biologic agents.

Smallpox, which is caused byinfection with poxvirus variola,may follow variouscourses. An erythematouseruption can precede theappearance of tense, deep-seatedpapules that rapidly transform intovesicles. The lesions may be sparseor so numerous that they becomeconfluent.

The emphasis in this clinically focused text is on syndromesand patient care rather than on pathogens. Among the topicscovered are antimicrobial pharmacokinetics and pharmacodynamics;head and neck infections; upper respiratory tractinfections; bronchitis and pneumonia; endocarditis; pericarditisand myocarditis; peritonitis, liver abscess, and biliary tractinfections; viral hepatitis; CNS infections; skin and soft tissueinfections; animal and human bites; osteomyelitis and infectiousarthritis; foot infections in patients with diabetes; scarletfever and toxic shock syndromes; fever of unknown origin;bacterial, viral, and protozoal diarrhea; obstetric-gynecologicinfections; urinary tract infections; sexually transmitted diseases;infectious complications of HIV infection; tuberculosis;tropical diseases; zoonoses; bioterrorism; and fungal infections.Color and black-and-white photographs, photomicrographs,CT scans, radiographs, drawings, tables, and flowchartshighlight seminal points in the text.

An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.

A 12-year-old black girl is hospitalized because of increasinglysevere dyspnea and sore throat. The sorethroat started about a week earlier and was accompaniedby fever and chills. The patient was evaluated at an urgentcare center when her symptoms worsened, where she wasgiven ampicillin for a presumptive “strep throat.” A generalizedmaculopapular erythematous rash developed within24 hours of the start of therapy, and the ampicillin waspromptly withdrawn. The rash cleared gradually thereafter.Now the patient’s sore throat has worsened to the pointthat she has difficulty with drinking and eating. She hasbecome increasingly dyspneic during the past 24 hours.

A 40-year-old man has had discomfort at the distal end of thefingers of both hands for several weeks. He has also noticed nail pitting andonycholysis. He denies any trauma or inciting event and has been otherwisehealthy. He has no family history of inflammatory bowel disease, althoughhe believes that some family members have had rashes.

Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.

A 1 X 0.5-cm hemorrhagic, polypoid lesion that had been present for 2 monthson a 13-year-old boy’s left anterior chest was excised. Pathologic examinationconfirmed the diagnosis of pyogenic granuloma.

A 38-year-old woman presents with a pruritic, tender rash on the trunk and extremitiesthat has not changed over the past few days. She has taken fluvastatinand sertraline for 1 year and a popular, over-the-counter weight-loss product for1 or 2 weeks. The patient denies using any other medications. She has had norecent illnesses.

Tortuous, dilated varicosities; multiple smaller caliberabnormal perforating vessels; and chronic brawnyedema of chronic venous insufficiency (CVI) were seenon a 70-year-old man’s left leg (A). He reported that theedema and discoloration had worsened over the last15 years. The brawny edema stopped just above theankle, indicating that compression by the patient’s sockcontrolled the signs and symptoms of CVI.

For 2 days, a 45-year-old woman has had a painful rash on her left upper chest,upper back, neck, shoulder, and upper arm; she has also had pain around herleft ear. She describes the pain as burning, needlelike, and so severe that it hasprevented sleep; it is unrelieved by topical emollients. The rash was precededby 24 hours of a similar burning pain in the same area. No neurologic deficitsare associated with the rash. She has no history of rashes; no pain or rashesoccur elsewhere on her body.

For about 3 to 4 months, a 53-year-old man has had gradually worsening footdiscomfort. He describes the discomfort as a burning sensation accompaniedby numbness and tingling. Initially, these symptoms were present only in hisfeet, but for several weeks they have involved both ankles as well. Althoughthe discomfort is always present, it is occasionally aggravated by the bed coversor by heavy woollen socks. The patient has no skin lesions, motor symptoms,or other abnormalities of his legs or feet.

An 18-month-old girl presents with a mass in the lateralupper right orbital area (lateral brow). The lesion can bepalpated beneath the eyelid just inside the lateral aspect ofthe orbital rim. The lesion does not appear to interferewith the girl’s vision. The extraocular movements all appearnormal and, grossly, the child appears to visualizenormally with her right eye. CT reveals a well-circumscribed,cystic mass without bony involvement or deep intracranialextension.

For 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year

The parents of a 3-year-old girl seekmedical evaluation of the nodules ontheir daughter’s back. The lesionshave been present since birth andhave grown with the child.

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.

A 47-year-old woman is bothered by the numerous small, smooth, darkbrown papules that have developed on her face and neck during the pastdecade. She asks if the asymptomatic lesions can be removed.

During the past 3 decades, the prevalence of asthma andallergies in children has increased steadily. Today, about 5million American children have asthma, which is the leadingcause of absence from school. The editors and authors ofthis textbook-who are recognized authorities in theirfields-discuss recent advances in the field of allergy andimmunology and tailor this new information to the specialneeds of children. Children’s immune systems are in theprocess of development; this offers special opportunities forprevention and intervention. Presented here is detailedguidance in the diagnosis and management of immunologicdiseases, upper airway allergies, asthma, food allergies, allergicskin and eye diseases, and drug allergies. Differentialdiagnoses, approaches to evaluation, environmental triggers,and both established and emerging treatments are alladdressed. The latest immune-directed therapies are discussedin depth. Photographs, graphs, tables, and figuresappear throughout the text.

An 11-year-old boy has had a persistent foot rash since he started to play baseball2 months earlier. The eruption has not responded to over-the-counter antifungalcreams.

A 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.

A 36-year-old womanhas had a rash on her hands and feetfor the past week. She denies recentillness, pruritus, fever, chills, sorethroat, and abdominal discomfort.She is currently in a monogamousrelationship with her fiancé.

For 3 days, a 60-year-old woman hashad a tender rash on her forehead. Thelesions erupted 2 days after she sustainedminor trauma to the left side ofthe forehead (Figure 1); no scratchesor bleeding were associated with theinjury. She noted a burning sensationand mild tenderness at the site shortlybefore the lesions arose.

Prolonged exposure to coldtemperatures can have a profoundeffect on the skin.When tissues are exposed toabove-freezing temperatures,localized vasoconstriction and increasedblood viscosity reduce bloodflow and decrease the amount ofoxygen available to tissues. Whentissues are exposed to freezing temperatures,water within those tissueschanges into ice crystals; this resultsin either intracellular or extracellulardamage and tissue necrosis.

A 73-year-old man is admittedto the hospital with pulmonary tuberculosis.A 3-drug fixed combination-isoniazid, rifampicin, and pyrazinamide-and ethambutol are given.Within an hour, a global urticarialrash erupts (A and B).

A 23-year-old woman presented with medial and lateralpruritic keloids on her right earlobe, which had beenpierced several years earlier. These lesions began to developduring the patient’s pregnancy 2 years earlier.Keloids also were noted on the presternal region. Thepatient reported that these had begun as pimples thatspontaneously enlarged.

My patient is a 7-year-old girl with multiple plantar warts on both feet.

A 10-year-old boy presents with abdominaldistension that has progressed slowlyfor the past 2 years. The distension,which is painless, does not impair hisdaily activities. He has not observedany changes in bowel or voiding habits.

A 3-year-old boy is brought to the office by his mother. Theprevious evening, she had noticed a single large red spot on the back of histhigh. This morning, his whole body was covered with a similar rash, andhe had a temperature of 38.8°C (102°F). The mother administered 1 doseof acetaminophen at home for the fever; the rash was asymptomatic.

Allopurinol has been usedto treat gout for well over3 decades. In addition,this drug is prescribed toprevent urate nephropathyin patients who are receiving cancerchemotherapy.

For several months, a 59-year-oldwoman has had numerous asymptomaticlesions on her arms andlegs. During this period, she has notbeen exposed to the sun and hastaken no new medications.