Burns, Vascular Tumors, and Nail Changes PDF

Burns, Vascular Tumors, and Nail Changes Dr. James Lyons Associate Dean of Medical Education Professor of Pathology & Family Medicine  Objectives § Describe the features of first, second, third, and fourth degree burns § Descr...

Burns, Vascular Tumors, and Nail Changes Dr. James Lyons Associate Dean of Medical Education Professor of Pathology & Family Medicine  Objectives § Describe the features of first, second, third, and fourth degree burns § Describe the features of partial-thickness and full-thickness burns § Know how to calculate the percentage of body surface involved for burns in an adult § Know how to calculate the appropriate amount of IV fluid for resuscitation of a burn victim using the Parkland formula § Describe the etiology, epidemiology, clinical presentation, histologic findings (if given), diagnosis, and clinical course/treatment of vascular tumors including pyogenic granuloma, cherry hemangioma, bacillary angiomatosis, glomus tumor, Kaposi sarcoma, and angiosarcoma 2 § Identify nail changes and their underlying causes  Burns Tissue injury due to heat, friction, electricity, radiation, or chemicals. An estimated 450,000 individuals in the United States receive medical treatment each year for burn injuries. Although 40,000 patients require hospitalization and more than 60% of those are treated at one of 127 specialized burn centers, the vast majority of burn patients are treated in the acute setting by emergency physicians and discharged with outpatient follow- up.  Thermal Burns 6 hours for burns to occur at 111 degrees F (44 C) 1 second for burns to occur at 140 degrees F (60 C)  Burns The severity of a burn is judged by the depth of the burn and the percent of body surface area (BSA) that is involved Body surface area (rule of 9’s) – For adult : Entire head and neck 9%, Entire right arm 9%, Entire left arm 9%, Entire right leg 18%, Entire left leg 18%, Entire anterior torso 18%, Entire posterior torso 18%, perineum 1% Infant up to 1 yo The skin is still able For each year >1 yo, to retain fluids if the subtract 1% from head burn is a first degree and add 0.5% to each leg burn, so only burns of the second degree or worse are used to calculate BSA for burns***. Adult and 13.5% 13.5% Child > 10 yo  Burns First degree burn (AKA superficial burn) – Affects epidermis only – Painful, skin typically appears red or pink Heals without sequelae as epidermis is regenerated  Burns Second degree burn (AKA partial thickness burn) – Affect epidermis and part of the dermis May be subdivided into: – 1. Superficial partial thickness burn » Involves epidermis and superficial dermis » Often see redness and blisters, painful, usually heal without scarring – 2. Deep partial thickness burn » Involves epidermis, papillary dermis, and reticular dermis » Often see redness and blisters, painful but may be less pain than expected due to nerve destruction, heal with scarring , often treated with skin grafting to improve outcome  Burns Third degree burn (AKA full thickness burns) – Affect epidermis, entire dermis, and variable amount of subcutaneous tissue – Leathery white appearance – Often insensate (not painful) – Generally require skin grafting  Time For Full Thickness Burns To Occur In Scalding Water 5 seconds in water @ 140 F (60 C) 30 seconds in water @ 130 F (55 C) 5 minutes in water @ 120 F (49 C)  Burns Fourth degree burn – Affect entire thickness of skin plus underlying muscle or bone – Black charred skin  Burns http://jamanetwork.com/journals/jama/fullarticle/184786 Summary of Burns  Keloid Scars On Both Sides Of Earlobe Keloid Scar After Severe Burn After Ear Piercing Keloid scars have raised areas and extend beyond the original area of an injury  Treatment of Burns Maintain adequate oxygenation – Evaluate airway for evidence of inhalation injury – Evaluate for carbon monoxide poisoning Pain control Wound care Fluid resuscitation – Parkland formula – Goal urine output 1 ml/kg/hr Parkland Formula  A 27 yo man has second degree burns involving the entire left anterior portion of his torso and his entire left arm. What percentage of his body surface has been burned per the Rule of 9’s? a) 9% b) 13.5% c) 18% d) 22.5% e) 27%  A 27 yo man has second degree burns involving the entire left anterior portion of his torso and his entire left arm. He weighs 100 kg. According to the Parkland formula, how many ml of LR should he be given in the first 8 hours? a) 1800 b) 3600 c) 5400 d) 7200 e) 9000 What rate should the IV infusion be set at initially? a) 300 ml/hr b) 350 ml/hr c) 400 ml/hr d) 450 ml/hr e) 500 ml/hr  Vascular Tumors Pyogenic granuloma Cherry hemangioma Bacillary angiomatosis Glomus tumor Kaposi sarcoma Angiosarcoma 19  Pyogenic Granuloma (PG) AKA lobular capillary hemangioma Background: – Benign vascular tumor – Misnomer – these lesions do not contains granulomatous inflammation or pus – Peak incidence in second and third decades of life – Often develop at site of previous injury – Display rapid growth – Associated with trauma, systemic medications, and pregnancy About 2 percent of pregnant women develop an intraoral PG in the first five months of pregnancy Clinical: – Solitary vascular papule or nodule with a glistening red to red-brown friable surface – Distribution - most commonly affects fingers, lips, mouth, trunk, and toes. Course: – Treatment is usually required for pyogenic granuloma (PG) because of frequent ulceration and bleeding. Treatment options include laser surgery, surgical excision, and curettage with electrodesiccation at the base. 20  Pyogenic Granuloma (PG) Medications – In one study, about 30 percent of cases of periungual or subungual PG were related to a systemic medication. Offending medications include: Systemic and topical retinoids, Epidermal growth factor receptor and tyrosine kinase inhibitors (e.g., cetuximab, imatinib), capecitabine and etoposide, 5-fluorouracil, cyclosporine, tacrolimus, docetaxel, granulocyte colony- stimulating factor, human immunodeficiency virus (HIV) protease inhibitors, BRAF inhibitors Histopathology: – Early lesions are identical to granulation tissue – Fully developed lesions are polypoid and show a lobular pattern of vessels with fibrous septae – Covered by thin epidermis 21 Pyogenic Granuloma (PG) 22 Pyogenic Granuloma (PG) 23  Cherry Hemangioma AKA cherry angioma, senile angioma, or Campbell de Morgan spot Background: – Benign vascular neoplasm – Appear in adulthood (in contrast to infantile/strawberry hemangiomas), often increase in number with age Clinical: – Typically a 0.1 to 0.4 cm red-brown papule, blanch with pressure – Distribution - most commonly presents with multiple lesions on the trunk Course: – Treatment of cherry angiomas is typically not required – Treatment options include: electrocautery after anesthesia with 1% lidocaine, shave excision and electrocauterization of the base, and pulsed dye vascular laser therapy 24  Cherry Hemangioma Histopathology – Dilated capillaries localized in the superficial dermis – Vessels have variably thickened walls – In older lesions there is loss of the rete ridges and atrophy of the superficial epidermis – Mast cells may be numerous 25 Cherry Hemangiomas 26 Cherry Hemangioma 27 Cherry Hemangioma 28  Bacillary Angiomatosis Background: – Vascular proliferative form of infection that occurs primarily in patients with HIV infection – Can involve the skin and/or internal organs – Causative microorganisms are Bartonella quintana and Bartonella henselae Clinical: – Red to purple papules that may increase in size to form nodules – Patient may have solitary or multiple lesions Course: – Bacillary angiomatosis can be cured in most patients with antibiotics – IDSA guidelines - Erythromycin or doxycycline are recommended for treatment of bacillary angiomatosis 29  Bacillary Angiomatosis Histopathology – Lobular pattern – Proliferation of capillaries separated by connective tissue – Endothelial cells and neutrophils – Bacteria 30 Bacillary Angiomatosis 31 Bacillary Angiomatosis 32  Glomus Tumor Background: – Benign vascular neoplasm – Derived from smooth muscle cells of glomus body (glomus bodies are involved in temperature regulation, contain arteriovenous shunt) Clinical: – Most commonly occur in fingers and toes – Pink or purple vascular papule or nodule – Commonly painful and tender Course: – Treatment is surgical excision Subungual glomus tumor http://www.eatonhand.com/img/img0 0090.htm 33  Glomus Tumor Histopathology; – Well-circumscribed dermal nodule composed of glomus cells, vasculature, and smooth muscle cells 34  Kaposi Sarcoma Background: – Malignant vascular neoplasm – Caused by infection of endothelial cells with human herpes virus type 8 (HHV- 8) – Seen predominantly in immunosuppressed patients (HIV infection, organ transplant recipients) Clinical: – Most commonly occurs on the legs but also occurs in lymph nodes, GI tract, and respiratory tract – Begins as red-brown to blue-purple macule. Macules evolve into patches, papules, plaques, and nodules. – GI involvement can lead to obstruction and bleeding in late stages. Pulmonary involvement can cause bronchospasm, coughing, shortness of breath, and progressive respiratory failure. Course – Treatment options include surgery, radiation therapy, cryotherapy, laser therapy, chemotherapy, immunomodulators (interferon alpha, thalidomide) – Data from the National Cancer Institute’s SEER program showed an overall 5- year relative survival of about 72% 35  Kaposi Sarcoma Classic Kaposi sarcoma of the feet with brownish to blue nodules and plaques, Deeply violaceous papules, nodules, and partially hyperkeratotic on the soles and plaques on leg of HIV+ patient lateral aspects of the feet. This is a typical localization of early classic KS 36  Kaposi Sarcoma Histopathology – Poorly formed vascular spaces in the dermis with frequent mitoses and a mononuclear cell infiltrate of lymphocytes, plasma cells, and macrophages 37  Angiosarcoma Background: – Malignant vascular neoplasm with atypical endothelial cells Risk factors: – Old age (mean age 65-70), lymphedema, radiation therapy, male gender (M:F=2:1) Clinical: – Seen in face, neck , and scalp of elderly patients – Seen in extremities of patients with lymphedema – Seen at sites of previous radiation therapy – Red-brown to blue-purple macules, patches, papules, plaques, and nodules. Course – Treatment is predominantly surgery, may also use radiation therapy, and chemotherapy – Poor prognosis: In a series of 133 angiosarcomas of the scalp and neck reported to the SEER database between 1973 and 2007, 5 and 10-year survival rates were 34% and 14% 38  Angiosarcoma Reddish-brown maculopapular lesion on nose Plaque with crusting on forehead and anterior scalp 39  Angiosarcoma Histopathology – Poorly formed vascular spaces spaces lined by endothelial cells with cytologic atypia of nuclei 40  Nail Changes/Disorders Acute paronychia Onychomycosis Subungual hematoma Clubbing Koilonychia Beau lines Muehrcke lines Terry nails  Acute Paronychia Paronychia- A superficial infection of the proximal and lateral nail folds adjacent to the nail plate that has been present for less than six weeks (acute) Most commonly caused by the inoculation of pathogens present in the skin flora (e.g., Staphylococcus aureus, Streptococcus pyogenes) into the periungual tissues by minor mechanical or chemical traumas that disrupt the nail fold barrier The nail folds are often red, swollen, and tender May develop associated abscess Tx: topical antibiotics/warm soaks, oral antibiotics in nonresponders, I&D for abscess 42  Onychomycosis Fungal infection of nail due to dermatophyte, yeast, or nondermatophyte mold – Most common cause is Trichophyton rubrum Presents with nail discoloration (often white or yellow), subungual hyperkeratosis, splitting of nail, onycholysis (separation of nail from nailbed), and/or nail plate destruction KOH prep can be used to confirm dx TX: oral antifungal therapy is considered the gold standard treatment for onychomycosis because of higher complete cure rates and shorter courses of treatment when compared with topical therapy, oral terbinafine is the first-line oral agent dermatophyte onychomycosis  Subungual hematoma Blood under the nail, usually due to trauma May cause throbbing pain Can perform drainage/trephination of fresh hematomas Can also remove nail if symptomatic/painful  Clubbing Clubbing involves thickening of the nail bed's soft tissue, particularly in the proximal end This condition usually affects all of the fingernails and rarely occurs in a single digit. Clubbing can be clinically diagnosed with an exam showing Schamroth sign (below; absence of the diamond-shaped opening that normally appears when the digits are opposed) Clubbing is thought to be secondary to altered vasculature. It is theorized that the thickening of the soft tissue develops from increased blood flow within the microvasculature, instead of within the larger capillaries. Clubbing can be a sign of numerous underlying diseases, such as cirrhosis, chronic obstructive pulmonary disease, lung cancer, or celiac sprue  Koilonychia Also called spoon nail Upward curving of the distal nail plate that results in a spoon-shaped nail that could hold a drop of water on the surface Associated with iron deficiency anemia Can also be seen in hemochromatosis, trauma, Raynaud disease, hypothyroidism, systemic lupus erythematosus, occupational exposure to petroleum-based solvents,  Beau Lines Horizontal grooves on the nail plate caused by an interruption of nail bed mitosis. Etiologies include severe illness, Reynaud disease, pemphigus, chemotherapy/drugs, high fever, viral infections, local trauma, Kawasaki disease TX: no specific treatment other than treating any underlying condition  Muehrcke lines Typically appear as a couple of transverse, white bands that run parallel to the lunula across the entire width of the nail On examination, they will disappear when pressure is applied to the nail plate Etiologies include hypoalbuminemia, nephrotic syndrome, liver disease, malnutrition TX: no specific treatment other than treating any underlying condition  Terry Nails Terry's nails (two-thirds nails) typically results in apparent leukonychia (white discoloration) of all but the most distal 2 mm of the nail bed. Application of pressure resolves the leukonychia First described in patients with alcoholic liver cirrhosis, Have since been described in a number of systemic diseases, including autoimmune hepatitis, diabetes mellitus type 2, rheumatoid arthritis, Reiter syndrome, and congestive heart failure  References 1. Kumar K, Abbas A, Fausto, and Aster Pathologic Basis of Disease, 9th edition 2. Fitzpatrick's Dermatology in General Medicine, 8e, Lowell A. Goldsmith, Stephen I. Katz, Barbara A. Gilchrest, Amy S. Paller, David J. Leffell, Klaus Wolff 3. AAD Dermatology Medical Student Core Curriculum 4. Access Medicine 5. UpToDate 6. https://www.aafp.org/afp/2012/0415/p779.html#afp20120415p779-f11 7. VisualDx