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Urgencies and Emergencies: When to Worry

Featuring Robert Micheletti, MD

Dr. Robert Micheletti explored urgent and emergent presentations in the dermatology patient. Dr. Micheletti began his lecture stating there is “no predicting what walks through the door” and therefore it is essential to recognize skin lesions and “red flags” to know when a situation demands urgent attention.

Violaceous and necrotic lesions need rapid diagnosis via biopsy and tissue culture as these lesions are signs of ischemia or tissue death. Dr. Micheletti reports “there is nothing good on the list” when you see vascular destruction. The differential of these types of lesions include infectious processes, vasculitis, vasculopathies, coagulopathies and depositional conditions.

Violaceous and necrotic lesions need rapid diagnosis via biopsy and tissue culture as these lesions are signs of ischemia or tissue death…

Dr. Micheletti reported it is essential to recognize immunosuppression in our patients as these patients can become very sick very fast. Aspergillus is the most common opportunistic infection in transplant patients. Additionally, when working up a patient with a concerning cutaneous presentation, it is crucial to identify any additional signs of systemic illness with constitutional symptoms such as fever, hypotension and tachycardia. Furthermore, it is important ask questions about inflammatory arthritis, gastrointestinal or pulmonary symptoms.

Dr. Micheletti reports “never assume someone knows better or has it covered” and “don’t be afraid to advocate for your patient” when managing patients with concerning symptoms. It is essential to follow through and communicate with other providers. The dermatology provider can help differentiate between inflammatory and infectious condition such as in the case of pyoderma gangrenosum.

The dermatology provider can help differentiate between inflammatory and infectious condition such as in the case of pyoderma gangrenosum.

Ludwig’s angina is a crucial condition to diagnose and refer immediately. This condition can cause airway compromise due to a cellulitis like reaction of the tissue. If a patient presents with symptoms concerning for this condition, they need to be immediately referred to the emergency room. Dr. Micheletti reports in cases such as this “be humble, but don’t doubt your insights”.

Finally, vasculitis cases were illustrated with Dr. Micheletti emphasizing the importance of evaluating renal function in these patients. He illustrated a rare presentation of vitamin C deficiency with purpura not quite consistent with vasculitis. Corkscrew hairs were noted on this patient as a clinical clue. Finally, Dr. Micheletti presented cases of anti-MDA5-associated dermatomyositis which presents with rapidly progressive interstitial lung disease.

Byline: Sarah Patton, MSHS, PA-C
Posted: June 8, 2019




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