December 15th, 2012
We asked you about the treatment to this skin rash… and the answer is….
a. Coal Tar
This is the classic salmon pink rash of psoriasis. You can see the surface has a scaly appearance.
As the rash in psoriasis is palpable and spread over an area of >0.5cm it is called a plaque not a macule – (If it was an impalpable area of colour change it would be called a patch).
Skin psoriasis is treated by emmollients, vitamin D analogues, coal tars, dithranol, topical steroids and oral retinoids. Methotrexate and Anti TNF therapy in addition to other immune modulating therapies are used in severe cases. Remember the four main types:
- plaque (seen here)
- pustular (pustules often occuring on the hands and feet)
- guttate ( teardrop lesions -sometimes occuring following a streptococcal infection)
- erythrodermic (diffuse skin involvement – potentially lifethreatening)
Capsaicin is a Rubefacient: a topical skin irritant. Its use is based on the principle that irritation of the skin produces a “distracting” effect from the pain from OA/ neuropathy (e.g. post herpetic neuralgia).
It is used topically for osteoarthritis and neuropathic pain.
Capsaican is the “active” ingredient in chillies which gives them their heat. Its use over a rash like psoriasis would be liable to produce excruciating pain and significant inflammation.
November 22nd, 2012
Look at this skin rash. It measures 6cm in length and is occurring over the extensor aspect of the upper forearm.
Which of the following treatments is likely to result in the resolution of the rash?
a. Coal Tar
b. Mesalazine
c. Flucloxacillin
d. Topical ibuprofen
e. Topical capsaicin
Leave your answers as a comment below! Answer in a few days…
October 15th, 2012
We asked you about this 27 year old female who presented with a 3-day headache. After looking at her lumbar puncture results, the diagnosis is….
a. Benign Intracranial Hypertension
The pressure is very high! The CT was normal essentially excluding raised intracranial pressure secondary to an obstructive hydrocephalus (e.g. meningioma obstructing the 4th ventricle draining CSF). The red cells are high in the first sample of CSF but as further CSF is tapped off, this clears. This supports a slightly “traumatic” tap. Xanthochromia testing in the sample is negative, providing no evidence of a prior bleed into the CSF which has then been broken down into xanthochromia.
To diagnose a S.A.H. you have to have either blood or altered blood in the CSF. As a rule of thumb you should have “no” red cells in the CSF if its not a traumatic tap and there is no other pathological processes.
The diagnosis is BIH. This is reasonably common in young people and is not benign: untreated it can threaten sight. Treatment is via means to reduce CSF pressure e.g. repeated lumbar punctures.
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September 29th, 2012
A 27 year old female presents with a headache. She has had it for 3 days. She has no other symptoms. She has a normal CT brain.
Her lumbar puncture shows the following.
| CSF Opening Pressure (10-20cm H20) |
42 |
| Macroscopic appearance |
Clear |
| Bottle 1Bottle 3 |
RBC 150 mm3, WCC 0mm3RBC 0mm3,WCC 0mm3 |
| Gram stain |
Negative |
| MCS |
No growth |
| Glucose |
4.5 |
| Xanthochromia |
negative |
What is the most likely diagnosis?
a. Benign Intracranial Hypertension
b. Tension headache with traumatic Lumbar Puncture
c. Sub arachnoid haemarrage missed on CT
d. Stroke
e. Sub Arachnoid Haemorrage
f. TB Meningitis
Leave your answer below!
September 26th, 2012
We got over 50 responses to our question of the day on this needlestick injury. And the answer is….
b. The chance of transmission of hepatitis C is around 3%
The chances of transmission are as follows:
|
Condition
|
Notes
|
| HIV/AIDS 0.3% |
Risk assessment needed prior to administering post exposure prophylaxis |
| Hep C 3%1 |
PCR testing for Hep C virus will give most accurate and reliable indication of transmission |
| Hep B 30% |
Consider repeat Hep B booster/ IvIG (local policies) |
|
The rule of 3′s
|
The risk is higher with hollow bore needles than with normal needles (e.g. suturing). This data varies widely across specialities. Individuals vaccinated against Hepatitis B have a lower risk of transmission following a needle stick.
The prevalence of needle stick injuries has been estimated to be as high as 33% in a 6 month period for healthcare workers.3
Hep B is the most transmissible of all 3 conditions. As a healthcare professional with a transmittable disease it may preclude you from working in certain specialities e.g. some surgical specialities.
Remember the prevalence of Hepatitis B, HIV and Hepatitis C in the UK is still low (<1% for each).
1. The risk of Hep C transmission rate varies from 3-5%. If a person is exposed, the usual practice is to PCR the blood for the hepatits C virus .
MS Sulkowski et al. Needlestick transmission of hepatitis C. JAMA 2002 287: 2406-2413.
2. A study of 75 medical students and interns in New York
F Resnic, MA Noerdlinger. Occupational exposure among medical students and house staff at a New York City medical center. Archives of Internal Medicine 1995 155: 75-80.
A good review can be read from Bandolier here.
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