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Dermatologic disorders that are associated with emergency department visits in the US: Results from a nationally representative US sample
4571
5014
Dermatitis herpetiformis presenting as pseudovasculitis Kevin H. Kim, MD, University of Arkansas for Medical Sciences; Malan Kern, BS, University of Arkansas for Medical Sciences; Spencer D. Hawkins, BS, Wake Forest University; Gina Johnson, MD, University of Arkansas for Medical Sciences; Henry K. Wong, MD, University of Arkansas for Medical Sciences
Dermatologic disorders that are associated with emergency department visits in the US: Results from a nationally representative US sample Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario; Branka Vujcic, BS, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario; Aditya K. Gupta, MD, Department of Medicine, Faculty of Medicine, University of Toronto Background: There is essentially no data on dermatologic conditions that result in emergency department visits in the US. Purpose: Examine the types of dermatologic disorders that bring patients to the emergency department (ED) in a nationally representative US sample.
Introduction: Dermatitis herpetiformis (DH) is a cutaneous manifestation of gluten intolerance that characteristically presents as an intensely pruritic papulovesicular eruption with a predilection for the extensor extremities, scalp, and buttocks. Due to its variable clinical presentation, DH can be a challenging clinical diagnosis with subsequent histopathology and immunofluorescence being vital in confirming the diagnosis. Herein, we report a case of a 47-year-old patient who presented with clinical features resembling vasculitis but with classic histopathology and immunofluorescence findings for DH. Case report: A 47-year-old white man with a 7-year history of DH presented to the emergency department for the evaluation of a generalized petechial rash. He first noticed the rash about a month prior after discontinuing dapsone, but it had gotten progressively worse over the preceding week. The rash was initially pruritic but developed into severe burning pain. Physical examination showed well-demarcated erythematous macules coalescing into larger patches on the upper back, buttock, and trunk. In addition, purpuric macules and patches were noted on the anterior shins, knees, and anterior thighs. Biopsy of left anterior thigh showed a subepidermal blister with aggregates of neutrophils within the papillary dermal tips. There was pronounced dermal hemorrhage, but no evidence of leukocytoclastic vasculitis was identified. Direct immunofluorescence (DIF) showed granular IgA deposition in the papillary dermal tips. Given the overall clinical, histopathologic, and DIF findings, a diagnosis of DH was favored. Patient was restarted on dapsone and topical corticosteroids for management of DH. Discussion: Our patient’s clinical presentation with remarkable purpuric macules and patches alongside diffuse confluent erythematous macules and patches is an unusual presentation of DH. While a vasculitic process was initially favored in the differential diagnosis due to the exuberant clinical appearance, no evidence of leukocytoclastic vasculitis was seen on histopathology, but rather dermal hemorrhage favoring pseudovasculitis, which is known to simulate vasculitis. The pleomorphic clinical appearance of DH can be challenging in the diagnosis of DH. Awareness of its clinical variability can avoid misdiagnosis and delay in treatment. Commercial support: None identified.
4730 Dermatologic diagnosis of neurologic disease: The presence of phosphorylated tau protein in buccal cells of Alzheimer’s disease patients Sami Saikaly, BS, University of Central Florida College of Medicine; William Eng, MD, University of Central Florida College of Medicine; Luis Fernando Arredondo, Universidad Aut onoma de San Luis Potosı; Saray ArandaRomo, Universidad Aut onoma de San Luis Potosi; Erika Chi-Ahumada, BS, Universidad Aut onoma de San Luis PotosıWebsiteDirections; Maria JimenezCapdeville, PhD, Universidad Aut onoma de San Luis Potosı; Robert Norman, DO, University of Central Florida College of Medicine
Methods: We examined patient visits (1995-2011) from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Care Survey (NHAMCS); NHAMCS includes visits to the Outpatient Department (NHAMCS-OPD) and ED (NHAMCS-ED). The NAMCS/NHAMCS code up to 3 diagnoses per patient visit, using the ICD9-CM. A ‘comprehensive dermatology’ variable (DERM) was created to include the following: ‘diseases of the skin and subcutaneous tissue’(ICD9-CM 680709); ‘symptoms, signs and ill-defined conditions’ involving skin and other integumentary tissue (all 782 codes; 780.8 for generalized hyperhidrosis) and codes for melanoma and nonmelanoma skin cancers, benign skin tumors, viral and fungal infections of the skin, syphilis, skin diseases affecting the eyelids, and congenital anomalies involving the skin. SPSS 24 complex samples module was used for data analysis. Results: DERM ED visits (51.9% 6 0.4% female; mean 6 age: 34.30 6 0.28 years) represented an estimated 6.2% 6 0.2% (unweighted count ¼ 29,431, representing an estimated 106 million patient visits) of all DERM patient visits. Some of the most common ED dermatologic diagnoses (with their respective ICD9-CM codes) were ‘cellulitis and abscess’ (681, 682) (38.8% 6 0.8%); followed by ‘Ill-defined skin conditions’(782,780.0) (18.4% 6 0.4%); ‘contact dermatitis and eczema’ (692) (12.0% 6 0.3%); ‘urticaria’ (708) (6.5% 6 0.2%); ‘dermatophytosis’ (110) (3.1% 6 1.1%); ‘chronic ulcer of skin’ (707) (2.3% 6 0.1%); and atopic dermatitis (691) (2.1% 6 0.1%). In contrast to nonemergency visits (NAMCS, NHAMCS-OPD) some of the following DERM conditions were significantly more common in the ED: several skin infections such as ‘carbuncle and furuncle’ (680): OR ¼ 2.47 (95% CI, 1.89-3.22); ‘impetigo’ (684): OR ¼ 1.45 (95% CI, 1.22-1.73); ‘urticaria’ (708): OR ¼ 4.16 (95% CI, 3.69-4.70), and ‘ill-defined conditions relating to skin’ (782,780.8): OR ¼ 1.70 (95% CI, 1.59-1.81). Comment: It is not surprising that acute skin infections and urticaria were among the common ED DERM visits in the US. It is noteworthy that about 18% of ED DERM visits were classified as ‘ill-defined conditions’- to our knowledge this has not been previously recognized and requires further study. Commercial support: None identified.
Background: The link between neurology and dermatology is novel. The pathologic marker of Alzheimer’s disease (AD) is the presence of phosphorylated Tau protein (pTau) aggregates in brain structures devoted to memory (ie, hippocampus). Our previous studies have shown that skin punch biopsies from AD patients stain higher for p-Tau, opening the possibility of detecting neurologic disease via skin analyses. We have also related p-Tau to other skin pathologies; p-Tau and Ki-67, a well-known proliferation marker, stain positively in squamous cell carcinoma in situ, squamous cell carcinoma, and basal cell carcinoma. Since punch biopsies are invasive for a screening test, a more suitable alternative for AD detection may be a buccal swab. It is also of interest to elucidate if Tau pathology from the brain is connected to peripheral tissues through neural pathways, or via independent expression in non-neural tissues. Objectives: Determine the presence of Tau immunopositivity in buccal swabs from living AD patients and compare it with Tau pathology in hippocampal and brainstem samples from cadavers with neurodegenerative disease. Methods: Buccal swabs from AD patients and healthy controls were obtained and immunostained for p-Tau. Results were expressed as a percentage of positively immunostained cells. Hippocampal and brainstem samples from 10 cadavers were collected and immunostained for p-Tau to identify Tau pathology and make a comparison between both regions. Results: p-Tau immunostaining was significantly higher (P ¼ .04) in buccal swabs from AD (median 45%, range 17-98%, n ¼ 11) than from healthy controls (median 18%, range 0-48%, n ¼ 7). Despite the presence of severe Tau pathology in the hippocampus (n ¼ 10), the brainstem samples did not show it. Discussion: In addition to our previous findings of Tau immunopositivity in epidermal cells, these results demonstrate the presence of p-Tau immunoreactivity in oral mucous cells. This supports the hypothesis that Tau proteinopathy is not only expressed in neurons, but also in other cells of ectodermal origin. However, as Tau immunopositivity was not present in brainstems of cadavers with a history of neurodegenerative disease, despite the presence of positive neurofibrillary tangles in the hippocampal area, a potential pathway of Tau pathology connecting the brain with the periphery requires further study. Conclusion: These results support the hypothesis that the skin reflects cellular events related to brain pathology. Commercial support: None identified.
AB94
J AM ACAD DERMATOL
JUNE 2017
5014
Dermatitis herpetiformis presenting as pseudovasculitis Kevin H. Kim, MD, University of Arkansas for Medical Sciences; Malan Kern, BS, University of Arkansas for Medical Sciences; Spencer D. Hawkins, BS, Wake Forest University; Gina Johnson, MD, University of Arkansas for Medical Sciences; Henry K. Wong, MD, University of Arkansas for Medical Sciences
Dermatologic disorders that are associated with emergency department visits in the US: Results from a nationally representative US sample Madhulika A. Gupta, MD, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario; Branka Vujcic, BS, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario; Aditya K. Gupta, MD, Department of Medicine, Faculty of Medicine, University of Toronto Background: There is essentially no data on dermatologic conditions that result in emergency department visits in the US. Purpose: Examine the types of dermatologic disorders that bring patients to the emergency department (ED) in a nationally representative US sample.
Introduction: Dermatitis herpetiformis (DH) is a cutaneous manifestation of gluten intolerance that characteristically presents as an intensely pruritic papulovesicular eruption with a predilection for the extensor extremities, scalp, and buttocks. Due to its variable clinical presentation, DH can be a challenging clinical diagnosis with subsequent histopathology and immunofluorescence being vital in confirming the diagnosis. Herein, we report a case of a 47-year-old patient who presented with clinical features resembling vasculitis but with classic histopathology and immunofluorescence findings for DH. Case report: A 47-year-old white man with a 7-year history of DH presented to the emergency department for the evaluation of a generalized petechial rash. He first noticed the rash about a month prior after discontinuing dapsone, but it had gotten progressively worse over the preceding week. The rash was initially pruritic but developed into severe burning pain. Physical examination showed well-demarcated erythematous macules coalescing into larger patches on the upper back, buttock, and trunk. In addition, purpuric macules and patches were noted on the anterior shins, knees, and anterior thighs. Biopsy of left anterior thigh showed a subepidermal blister with aggregates of neutrophils within the papillary dermal tips. There was pronounced dermal hemorrhage, but no evidence of leukocytoclastic vasculitis was identified. Direct immunofluorescence (DIF) showed granular IgA deposition in the papillary dermal tips. Given the overall clinical, histopathologic, and DIF findings, a diagnosis of DH was favored. Patient was restarted on dapsone and topical corticosteroids for management of DH. Discussion: Our patient’s clinical presentation with remarkable purpuric macules and patches alongside diffuse confluent erythematous macules and patches is an unusual presentation of DH. While a vasculitic process was initially favored in the differential diagnosis due to the exuberant clinical appearance, no evidence of leukocytoclastic vasculitis was seen on histopathology, but rather dermal hemorrhage favoring pseudovasculitis, which is known to simulate vasculitis. The pleomorphic clinical appearance of DH can be challenging in the diagnosis of DH. Awareness of its clinical variability can avoid misdiagnosis and delay in treatment. Commercial support: None identified.
4730 Dermatologic diagnosis of neurologic disease: The presence of phosphorylated tau protein in buccal cells of Alzheimer’s disease patients Sami Saikaly, BS, University of Central Florida College of Medicine; William Eng, MD, University of Central Florida College of Medicine; Luis Fernando Arredondo, Universidad Aut onoma de San Luis Potosı; Saray ArandaRomo, Universidad Aut onoma de San Luis Potosi; Erika Chi-Ahumada, BS, Universidad Aut onoma de San Luis PotosıWebsiteDirections; Maria JimenezCapdeville, PhD, Universidad Aut onoma de San Luis Potosı; Robert Norman, DO, University of Central Florida College of Medicine
Methods: We examined patient visits (1995-2011) from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Care Survey (NHAMCS); NHAMCS includes visits to the Outpatient Department (NHAMCS-OPD) and ED (NHAMCS-ED). The NAMCS/NHAMCS code up to 3 diagnoses per patient visit, using the ICD9-CM. A ‘comprehensive dermatology’ variable (DERM) was created to include the following: ‘diseases of the skin and subcutaneous tissue’(ICD9-CM 680709); ‘symptoms, signs and ill-defined conditions’ involving skin and other integumentary tissue (all 782 codes; 780.8 for generalized hyperhidrosis) and codes for melanoma and nonmelanoma skin cancers, benign skin tumors, viral and fungal infections of the skin, syphilis, skin diseases affecting the eyelids, and congenital anomalies involving the skin. SPSS 24 complex samples module was used for data analysis. Results: DERM ED visits (51.9% 6 0.4% female; mean 6 age: 34.30 6 0.28 years) represented an estimated 6.2% 6 0.2% (unweighted count ¼ 29,431, representing an estimated 106 million patient visits) of all DERM patient visits. Some of the most common ED dermatologic diagnoses (with their respective ICD9-CM codes) were ‘cellulitis and abscess’ (681, 682) (38.8% 6 0.8%); followed by ‘Ill-defined skin conditions’(782,780.0) (18.4% 6 0.4%); ‘contact dermatitis and eczema’ (692) (12.0% 6 0.3%); ‘urticaria’ (708) (6.5% 6 0.2%); ‘dermatophytosis’ (110) (3.1% 6 1.1%); ‘chronic ulcer of skin’ (707) (2.3% 6 0.1%); and atopic dermatitis (691) (2.1% 6 0.1%). In contrast to nonemergency visits (NAMCS, NHAMCS-OPD) some of the following DERM conditions were significantly more common in the ED: several skin infections such as ‘carbuncle and furuncle’ (680): OR ¼ 2.47 (95% CI, 1.89-3.22); ‘impetigo’ (684): OR ¼ 1.45 (95% CI, 1.22-1.73); ‘urticaria’ (708): OR ¼ 4.16 (95% CI, 3.69-4.70), and ‘ill-defined conditions relating to skin’ (782,780.8): OR ¼ 1.70 (95% CI, 1.59-1.81). Comment: It is not surprising that acute skin infections and urticaria were among the common ED DERM visits in the US. It is noteworthy that about 18% of ED DERM visits were classified as ‘ill-defined conditions’- to our knowledge this has not been previously recognized and requires further study. Commercial support: None identified.
Background: The link between neurology and dermatology is novel. The pathologic marker of Alzheimer’s disease (AD) is the presence of phosphorylated Tau protein (pTau) aggregates in brain structures devoted to memory (ie, hippocampus). Our previous studies have shown that skin punch biopsies from AD patients stain higher for p-Tau, opening the possibility of detecting neurologic disease via skin analyses. We have also related p-Tau to other skin pathologies; p-Tau and Ki-67, a well-known proliferation marker, stain positively in squamous cell carcinoma in situ, squamous cell carcinoma, and basal cell carcinoma. Since punch biopsies are invasive for a screening test, a more suitable alternative for AD detection may be a buccal swab. It is also of interest to elucidate if Tau pathology from the brain is connected to peripheral tissues through neural pathways, or via independent expression in non-neural tissues. Objectives: Determine the presence of Tau immunopositivity in buccal swabs from living AD patients and compare it with Tau pathology in hippocampal and brainstem samples from cadavers with neurodegenerative disease. Methods: Buccal swabs from AD patients and healthy controls were obtained and immunostained for p-Tau. Results were expressed as a percentage of positively immunostained cells. Hippocampal and brainstem samples from 10 cadavers were collected and immunostained for p-Tau to identify Tau pathology and make a comparison between both regions. Results: p-Tau immunostaining was significantly higher (P ¼ .04) in buccal swabs from AD (median 45%, range 17-98%, n ¼ 11) than from healthy controls (median 18%, range 0-48%, n ¼ 7). Despite the presence of severe Tau pathology in the hippocampus (n ¼ 10), the brainstem samples did not show it. Discussion: In addition to our previous findings of Tau immunopositivity in epidermal cells, these results demonstrate the presence of p-Tau immunoreactivity in oral mucous cells. This supports the hypothesis that Tau proteinopathy is not only expressed in neurons, but also in other cells of ectodermal origin. However, as Tau immunopositivity was not present in brainstems of cadavers with a history of neurodegenerative disease, despite the presence of positive neurofibrillary tangles in the hippocampal area, a potential pathway of Tau pathology connecting the brain with the periphery requires further study. Conclusion: These results support the hypothesis that the skin reflects cellular events related to brain pathology. Commercial support: None identified.
AB94
J AM ACAD DERMATOL
JUNE 2017