AN OVERVIEW OF

MUCOCUTANEOUS SYMPTOM

COMPLEX

Part 2

ANTONIO E. CHAN, M.D.

 Classification

• Maculopapular eruption

• Vesiculobullous or vesiculopustular

• Petechial or purpuric eruption

 Definition & Pathogenesis

Blisters are circumscribed elevated

lesions filled with clear fluid
– Vesicles measure 5 mm or less in
diamter
– Bullae measure more than 5 mm in
diameter
 Definition & Pathogenesis

• Result from a disturbance of cohesion of

epidermal cells or components of the
basement membrane zone associated
with influx of fluid into or beneath the
site of disturbance
 Definition & Pathogenesis

• Depending on the mechanisms

responsible for their formation, blisters
can contain a combination of edematous
or lymphatic fluid, serum proteins,
antigen-antibody complexes, and
soluble inflammatory mediators.
 Pertinent Questions To Ask

• Patient’s age

• Season

• Exposure to infectious agents or medications

• History of previous disease

• Concurrent signs & symptoms

• Morphology, distribution and evolution of the

rash
 Viral Etiology of Vesiculobullous Lesions

• Varicella-zoster (wild and vaccine strains)

• Herpes simplex virus type 1 & 2

• Coxsackievirus A4, A5, A7-10, A16 & B1-3, B5

• Echovirus 4, 6, 9, 11, 17, 19, 33

• Enterovirus 7, 2

• Molluscum contagiosum
Bacterial Etiology of Vesiculobullous Lesions

• Staphylococcus aureus
– Bullous impetigo
– Scalded skin syndrome
• Ritter’s disease
• Lyell disease
• Streptococcus pyogenes
– Blistering distal dactylitis
– Ecthyma
– Erysipelas
– Non-bullous impetigo
– Scalded skin syndrome
• Disseminated gonococcal infection
Non-infectious Etiology of Vesiculobullous Lesions

• Stevens-Johnson syndrome

• Thermal injury

• Arthropod bites (Cimex spp.[bedbug],

Sarcoptes scabies)

• Contact dermatitis
VARICELLA
 VARICELLA

“dew drop-like lesions”

Skin lesions at various stages of evolution

HERPES ZOSTER
(SHINGLES)
ACUTE HERPETIC GINGIVOSTOMATITIS

Herpetic whitlow
 MOLLUSCUM CONTAGIOSUM
(WART)

Umbilicated lesions
IMPETIGO CONTAGIOSA
STAPHYLOCOCCAL SCALDED SKIN SYNDROME
Sunburst radial pattern

Positive Nikolsky sign

 DISSEMINATED GONOCOCCAL INFECTION
(ARTHRITIS-DERMATITIS SYNDROME)

 Discrete tender
necrotic pustules
with erythematous
base

 Arthritis
 ERYTHEMA MULTIFORME
(STEVENS-JOHNSON SYNDROME)

Cutaneous lesions are symmetric,

in crops and show predilection for
the extensor surfaces of the hands,
arms, feet, legs, palms and soles
 ERYTHEMA MULTIFORME
(STEVENS-JOHNSON SYNDROME)
Viral Etiology of Petechial or Purpuric Lesions

• Dengue virus (DHF)

• Measles virus (Black measles)

• Rubella virus (Congenital rubella

syndrome)

• Enterovirus
Bacterial Etiology of Petechial or Purpuric Lesions

• Neisseria meningitidis (Septicemia)

Non-infectious Cause

• Henoch Scholein Purpura

 Aedes aegypti

 Dengue transmitted by
infected female mosquito
 Primarily a daytime feeder
 Lives around human
habitation
 Lays eggs and produces
larvae preferentially in
artificial containers with clean
stagnant water
Dengue Clinical Presentations

 Undifferentiated fever – may be the

most common presentation*

 Classic dengue fever
 Dengue hemorrhagic fever (DHF)
 Dengue shock syndrome (DSS)
Clinical Characteristics of Dengue Fever

 In infants and young children

– Undifferentiated febrile illness
– Maculopapular rash
– Petechiae and a positive tourniquet test,
not uncommon
Clinical Characteristics of Dengue Fever

 Older children

– Mild febrile illness, or

– High fever with

 Severe headache

 Pain behind the eyes

 Muscle and joint pains

 Rash

 Petechiae and a positive tourniquet test

 Clinical Case Definition for
Dengue Hemorrhagic Fever

4 Necessary Criteria
 Fever, or recent history of acute fever
 Hemorrhagic manifestations
 Low platelet count (100,000/mm3 or less)
 Objective evidence of “leaky capillaries:”
 elevated hematocrit (20% or more over baseline)
 low albumin
 pleural or other effusions
 Clinical Case Definition for
Dengue Shock Syndrome
 4 criteria for DHF
 Evidence of circulatory failure manifested
indirectly by all of the following:
 Rapid and weak pulse
 Narrow pulse pressure (≤20 mm Hg) OR
hypotension for age
 Cold, clammy skin and altered mental status
 Frank shock is direct evidence of circulatory
failure
 Tourniquet Test

• Inflate blood pressure cuff

to a point midway between

systolic and diastolic pressure
for 5 minutes

• Positive test:
20 or more petechiae
per 1 inch2 (6.25 cm2)
Dengue Hemorrhagic Fever
Grading the Severity
Grade Manifestations

I Fever
Non-specific constitutional symptoms
such as anorexia, vomiting & abdominal
pain
II Manifestations of grade I plus
Spontaneously bleeding

III Manifestations of grade II plus

Circulatory failure

IV Manifestations of grade III plus

Profound shock
Hemorrhagic Manifestations of Dengue

 Skin hemorrhages:
petechiae, purpura, ecchymoses
 Gum bleeding
 Nose bleeding
 Gastro-intestinal bleeding:

hematemesis, melena, hematochezia

 Hematuria
 Increased menstrual flow
Dengue rash with blanching
DENGUE HEMORRHAGIC FEVER

Herman’s rash
 Meningococcal Infection

• Serogroups A, B, C, D, H, I, K, L, S, Y, Z, W135 & 29E

A, B, C account for more than 90% of meningococcal

disease worldwide

• The human nasopharynx is the only natural reservoir

• Transmission: respiratory droplet and requires close and

direct contact.

• Asymptomatic carriers are the most common source of

transmission
 Meningococcal Infection

• The spectrum of disease ranges from

asymptomatic transient bacteremia which
clears spontaneously to fulminant sepsis
resulting in death only a few hours after the
first symptoms occur

• The incubation period of invasive disease is

short
 Meningococcal Infection

• Risk factors associated with invasive disease

Host factors
– Young age
– Crowding
– Lower socio-economic class
– Concurrent upper respiratory infection
– Specific immune deficiencies (properdin or terminal
complement)
– Functional or anatomical asplenia
– Smoking (active or passive)
 Meningococcal Infection

• Risk factors associated with invasive disease

Pathogen factors
– Lipo-oligosaccharide (LOS) – pontent endotoxin
– Hypervariability of surface antigen
MENINGOCOCCAL INFECTION
Meningococcal infection
 Meningococcemia

WATERHOUSE FREDERICHSEN SYNDROME

 Hemorrhagic Measles
(Black Measles)

• A rare but fatal occurrence

• Characterized by sudden onset of high fever
accompanied by seizure or altered mental
state
• Pneumonia, hemorrhagic exanthem &
enathem
• Bleeding from the mouth, nose,
gastrointestinal tract & probable DIC
 HENOCH SCHONLEIN PURPURA

• A vasculitis of small vessels

• Etiology unknown
• Typically follows URTI
• 2 – 8 yr. of age
• Skin lesions appear in crops
• Rash begins as pinkish
maculopapules initially blanch
on pressure and progress to
petechiae or palpable purpura
(red – purple – rusty brown)
• Predilection over the dependent
areas or areas of greater tissue
distensibility
THANK YOU