Education
SELF-ASSESSMENT MINI-PROGRAM LAMAR S, OSMENT, M,D,
A 20-year-oId Caucasian man had a vesicular rash of 2 days' duration over t h e trunk and extremities with fewer lesions on the face. The palms and soles w e r e spared but on close examination o n e vesicular lesion was seen on the left cornea and a small ulcer was seen on the uvula. The only medication he had taken w a s 6 aspirin tablets since the onset of t h e disease. The patient had begun to feel bad about 4 days before admission. The eruption was preceded one day by a fever of 104° F orally. On further questioning, the patient admitted that he had noticed some shortness of breath and a v e r y slight cough. Careful physical examination showed that the pertinent findings were limited to the skin, visible mucous membranes and chest. Examinat i o n of the chest revealed a few moist rales throughout. The individual lesions revealed cloudy pustules. Frequently the roof of the vesicle was absent, leaving an umbilicated o r scratched out appearance to the lesions. Blood pressure was 100/70 rntn. T h e pulse rate was 104. The hemogram showed a white blood cell count of 3,800 p e r cubic mm. with a shift to the left, toxic granules and nutrophils, and a slight eosinophilia. The urinalysis revealed 1-[- proteinuria, scarce granular casts and a few degenerated leukocytes. T h e serologic test for syphilis was negative. 763
From ihe Divis'on oi Dcrmjio'ogy, Medical College of the University ol Alabania Birmingham, Aiabama
Hg, 1.
The patient was adtnitted to the hospital and placed in the isolation unit for observation. The fever continued at a high level while the skin lesions became
INTERNATIONAL JOURNAL OF DERMATOLOCY
764
December 1975
Vol. 14
crusted and began to dry over the next few days. A chest film obtained on the day of admission showed severe pneumonitis and extensive bilateral nodular pulmonary infiltrates. As the skin cleared during the ensuing few days, the pulmonary infiltrates disappeared.
3. Which of the following complications has not been reported to be associated with varicella?
1. At the time of admission a tentative diagnosis was made based on the clinical findings alone. Which of the following conditions would you have chosen?
4. As early as 1893 it was noticed that children exposed to adults with herpes zoster might develop varicella. Modern studies have been performed on the similarity of the two diseases. It is now thought that:
a. b. c. d.
Variola Erythema multiforme Varicella Hand, foot and mouth disease
2. On the second day of admission two vesicles from the abdomen of the patient were excised and sections were stained with hematoxylin and eosin. Which of the following was the pathologist likely to have observed? a, Intraepidermal vesicles b, Subepidermal vesicles c, A granulomatous reaction with giant cells cl. Chronic nonspecific dermatitis
a, b, c. d.
Purpura fulminans Photolocalized lesions Variola-like clinical picture Varicella nephritis
a. Herpes zoster and varicella are caused by two different viruses b. Herpes zoster and varicella are caused by the same virus
5. Realizing that the course is self-limited and recovery would be expected, which of the following might have some beneficial effect for the patient? a, b, c, d, e, f, g,
Thiosemicarbazones Idoxuridine Cytosine arabinoside Adenine arabinoside Amantadine Zoster immune globulin Interferon
Explanation and Answers to Self-Assessment Mini-Program
I . e . At that point, varicella was the most likely diagnosis considering the leukopenia, distribution of the lesions and pulmonary infiltrate. Pulmonary findings are mote common in adult varicella than in those cases seen in childhood. The absence of palmar and plantar lesions speaks against the diagnosis of variola. Lesions are seen in the pharynx and on the sclerae. Bronchial pneumonia, however, may occur in
variola. The absence of leukocytosis and lesions on the palms and soles would be against the diagnosis of erythema multiforme. 2. The correct answer is A. Blisters are unilocular from the onset. The balloon cells are large numbers of intranuclear inclusions. 3. D. Varicella nephritis has not been reported. Variolioid lesions, gangrenous
No.
10
SELF-ASSESSMENT MINI-PROCRAM • Osment
lesions and lesions provoked by sunlight have been reported in association with varicella, 4. B. Herpes zoster and varicella are probably caused by the same virus. Morphologically no differences are seen between the changes induced in cultures of human tissues by the agent of chicken pox and that of herpes zoster. Complement fixation and neutralization procedures have shown no significant antigenic differences between the two viruses. 5. The answers are A, C, D, and B. Thiosemicarbazones have proved lifesaving in patients with progressive generalized vaccinia and eczetna vaccinatum, especially in patients with impaired itnmunity. Its efficacy in varicella has not been proven, Idoxuridine, one of the pyrimidine nucleosides, was shown to have antiviral activity against several
765
DNA viruses. The agents have not been shown to be effective in varicella. Amantadine has been used only in the treatment of certain influenzas. Zoster imtnune globulin is probably helpful for the itnmune deficient patient. Initial studies in man have demonstrated that volunteers pretreated with a subcutaneous injection of monkey interferon were protected against vaccinia virus injected at the same site. No experience has been reported for humans. References 1, Blank, H,, and Rake, C , Viral and Rickettsiai Diseases of the Skin, Eye, and Mucous Membranes of Man, Boston, Little Brown & Co,, 1955, 2, Lever, W, F,, Histopathology of the Skin, Philadelpliia, |, B, Lippincott Co,, 1961, 3, Becker, F, T,, and Buckley, R, P,, Purpura Fulminans Associated wilh Varicella, Arch, Dermatol, 94:613, 1966,
Fitzherbert states in his Book of Husbandry in 1523 that scabies and lice of sheep should be treated with a mixture of tar in oil or grease. The same mixture was said to be useful to repel flies and the shepherd was advised never to be without his tar box. During the same period, old German veterinary texts advised the liberal use of sulfur in goose grease for skin diseases.—Muller, C. hi. and Kirk, R. W.; Stvail Anitnal Dertnatology. Philadelphia, W. B. Saunders Co., 1969, p. 430.
SELF-ASSESSMENT MINI-PROGRAM LAMAR S, OSMENT, M,D,
A 20-year-oId Caucasian man had a vesicular rash of 2 days' duration over t h e trunk and extremities with fewer lesions on the face. The palms and soles w e r e spared but on close examination o n e vesicular lesion was seen on the left cornea and a small ulcer was seen on the uvula. The only medication he had taken w a s 6 aspirin tablets since the onset of t h e disease. The patient had begun to feel bad about 4 days before admission. The eruption was preceded one day by a fever of 104° F orally. On further questioning, the patient admitted that he had noticed some shortness of breath and a v e r y slight cough. Careful physical examination showed that the pertinent findings were limited to the skin, visible mucous membranes and chest. Examinat i o n of the chest revealed a few moist rales throughout. The individual lesions revealed cloudy pustules. Frequently the roof of the vesicle was absent, leaving an umbilicated o r scratched out appearance to the lesions. Blood pressure was 100/70 rntn. T h e pulse rate was 104. The hemogram showed a white blood cell count of 3,800 p e r cubic mm. with a shift to the left, toxic granules and nutrophils, and a slight eosinophilia. The urinalysis revealed 1-[- proteinuria, scarce granular casts and a few degenerated leukocytes. T h e serologic test for syphilis was negative. 763
From ihe Divis'on oi Dcrmjio'ogy, Medical College of the University ol Alabania Birmingham, Aiabama
Hg, 1.
The patient was adtnitted to the hospital and placed in the isolation unit for observation. The fever continued at a high level while the skin lesions became
INTERNATIONAL JOURNAL OF DERMATOLOCY
764
December 1975
Vol. 14
crusted and began to dry over the next few days. A chest film obtained on the day of admission showed severe pneumonitis and extensive bilateral nodular pulmonary infiltrates. As the skin cleared during the ensuing few days, the pulmonary infiltrates disappeared.
3. Which of the following complications has not been reported to be associated with varicella?
1. At the time of admission a tentative diagnosis was made based on the clinical findings alone. Which of the following conditions would you have chosen?
4. As early as 1893 it was noticed that children exposed to adults with herpes zoster might develop varicella. Modern studies have been performed on the similarity of the two diseases. It is now thought that:
a. b. c. d.
Variola Erythema multiforme Varicella Hand, foot and mouth disease
2. On the second day of admission two vesicles from the abdomen of the patient were excised and sections were stained with hematoxylin and eosin. Which of the following was the pathologist likely to have observed? a, Intraepidermal vesicles b, Subepidermal vesicles c, A granulomatous reaction with giant cells cl. Chronic nonspecific dermatitis
a, b, c. d.
Purpura fulminans Photolocalized lesions Variola-like clinical picture Varicella nephritis
a. Herpes zoster and varicella are caused by two different viruses b. Herpes zoster and varicella are caused by the same virus
5. Realizing that the course is self-limited and recovery would be expected, which of the following might have some beneficial effect for the patient? a, b, c, d, e, f, g,
Thiosemicarbazones Idoxuridine Cytosine arabinoside Adenine arabinoside Amantadine Zoster immune globulin Interferon
Explanation and Answers to Self-Assessment Mini-Program
I . e . At that point, varicella was the most likely diagnosis considering the leukopenia, distribution of the lesions and pulmonary infiltrate. Pulmonary findings are mote common in adult varicella than in those cases seen in childhood. The absence of palmar and plantar lesions speaks against the diagnosis of variola. Lesions are seen in the pharynx and on the sclerae. Bronchial pneumonia, however, may occur in
variola. The absence of leukocytosis and lesions on the palms and soles would be against the diagnosis of erythema multiforme. 2. The correct answer is A. Blisters are unilocular from the onset. The balloon cells are large numbers of intranuclear inclusions. 3. D. Varicella nephritis has not been reported. Variolioid lesions, gangrenous
No.
10
SELF-ASSESSMENT MINI-PROCRAM • Osment
lesions and lesions provoked by sunlight have been reported in association with varicella, 4. B. Herpes zoster and varicella are probably caused by the same virus. Morphologically no differences are seen between the changes induced in cultures of human tissues by the agent of chicken pox and that of herpes zoster. Complement fixation and neutralization procedures have shown no significant antigenic differences between the two viruses. 5. The answers are A, C, D, and B. Thiosemicarbazones have proved lifesaving in patients with progressive generalized vaccinia and eczetna vaccinatum, especially in patients with impaired itnmunity. Its efficacy in varicella has not been proven, Idoxuridine, one of the pyrimidine nucleosides, was shown to have antiviral activity against several
765
DNA viruses. The agents have not been shown to be effective in varicella. Amantadine has been used only in the treatment of certain influenzas. Zoster imtnune globulin is probably helpful for the itnmune deficient patient. Initial studies in man have demonstrated that volunteers pretreated with a subcutaneous injection of monkey interferon were protected against vaccinia virus injected at the same site. No experience has been reported for humans. References 1, Blank, H,, and Rake, C , Viral and Rickettsiai Diseases of the Skin, Eye, and Mucous Membranes of Man, Boston, Little Brown & Co,, 1955, 2, Lever, W, F,, Histopathology of the Skin, Philadelpliia, |, B, Lippincott Co,, 1961, 3, Becker, F, T,, and Buckley, R, P,, Purpura Fulminans Associated wilh Varicella, Arch, Dermatol, 94:613, 1966,
Fitzherbert states in his Book of Husbandry in 1523 that scabies and lice of sheep should be treated with a mixture of tar in oil or grease. The same mixture was said to be useful to repel flies and the shepherd was advised never to be without his tar box. During the same period, old German veterinary texts advised the liberal use of sulfur in goose grease for skin diseases.—Muller, C. hi. and Kirk, R. W.; Stvail Anitnal Dertnatology. Philadelphia, W. B. Saunders Co., 1969, p. 430.
