Regarding disseminated gonococcal infection, which ONE of the following statements is TRUE?
Answer: B: The diagnosis of disseminated gonococcal infection should be suspected in a sexually active patient who complains of tenosynovitis and arthralgia associated with the typical rash. Although there are petechiae, the typical rash in disseminated gonococcal infection is more papular, vesicular or pustular skin lesions on the extensor surfaces of the wrists and hands and dorsal aspects of the ankles and feet and in the palms. The typical lesions are small papules or maculopapules with a red periphery and a petechial component. The number of lesions in the body can be up to 20. These lesions either become vesicles filled with purulent fluid or resolve rapidly. In spite of the disseminated infection the patient is not usually systemically toxic.
Neisseria gonorrhoea can be demonstrated with gram-staining of fluid obtained from the lesions and blood cultures often become positive in the early stages of the disease. However, the cultures remain sterile from specimen obtained from mucosal surfaces (e.g. urethral, cervical, vaginal). These should be tested for gonococcal antigens.
Reference:
Regarding drug eruptions seen in the ED, which ONE of the following statements is INCORRECT?
Answer: B: About 3% of the patients admitted to hospital have been found to have rashes due to adverse drug reactions and this number may be higher in patients presenting to the ED. Drug reactions can be due to true immunological hypersensitivity or allergy or can be due to non-immunological causes such as idiosyncratic reactions, irritant effects, toxicity and enzyme deficiencies.
One classification of drug eruptions is given below:
In the pathogenesis of TEN both type II (cytotoxic) and type IV (cell mediated) mechanisms are involved.
References:
Regarding blistering skin disorders that may be encountered in the ED, which ONE of the following statements is TRUE?
Answer: A: In children, when examining a rash, the presence of blisters in the skin narrows the possible differential diagnoses. The differential diagnosis for vesicles in children include infections such as HSV, varicella zoster virus (VZV), enterovirus, scabies, impetigo and tinea, various drug eruptions, insect bites, eczema, EM, photosensitivity and the rare condition called dermatitis herpatiformis. Larger blisters may occur in SSSS, SJS, immunologicallymediated bullous eruptions and in trauma and burns. Blisters occur as a result of accumulation of fluid within or under the epidermis. The clinical appearance of a blister may range from flaccid to tense and these blisters may remain intact or may rupture. These appearances generally depend on the level of intercellular split associated with a particular skin disorder. Three levels of epidermal split have been described:
Some bullous disorders are autoimmune disorders and at least nine such disorders have been described. Bullous pemphigoid is the most common and it affects mainly the elderly. There are different subtypes of pemphigus and some (e.g. pemphigus vulgaris) are potentially fatal.
Regarding hand, foot and mouth disease in children, which ONE of the following statements is INCORRECT?
Answer: B: Hand, foot and mouth disease is a common, infectious skin disorder most frequently affecting infants and young children. It can affect older children and adults occasionally. It is usually caused by coxackievirus A16 but some cases are caused by enterovirus 71. The condition is highly infectious and faeco-oral contamination is usually the mode of spread. The incubation period is 3–5 days and then small blisters appear on palms and soles and painful ulcers appear in the oral mucosa. The lesions may be present on buttocks of some children. The first week appears to be the most contagious; however, infected children may shed the virus in the faeces for weeks and continue to be contagious at a lower level. In addition the virus may be present in fluid of blisters, saliva and nasal secretions. EM, pustular psoriasis and EBV infection are some of the differentials to consider.
Regarding herpes simplex infections in children, which ONE of the following statements is INCORRECT?
Answer: D: The primary HSV infection acquired in the postneonatal period is caused by HSV type 1 and mainly affects the face. HSV type 2 infection is often sexually transmitted and may affect older children and adults.
Type 1 infection causes herpetic gingivostomatitis and ‘cold sores’ in children. It also can cause infections in the fingers, particularly in thumb and index fingers and this is called herpetic whitlow. Herpetic whitlow is often misdiagnosed as bacterial infection and/or abscess formation.
Eczema herpeticum is disseminated type 1 infection in association with atopic eczema. Patients with both mild and severe atopic eczema can be affected with this infection. The most severe disease can be seen in young children and adults who are immunosuppressed. Often the herpetic vesicles are quite atypical. The infection may appear as erosions associated with eczema and therefore misdiagnosed as exacerbation of eczema or as bacterial infection. Patients with severe disease should be treated with parenteral antivirals.
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