Moffitt Pearls 2/2/18 – Oral Lesions & SA Block

Thank you, Max, for presenting a case of a middle-aged man, HIV negative, with 2-3 weeks of cough, fevers, and scant hemoptysis, started on azithromycin and prednisone who 1 day later develops acute onset of a painless rash including the lips, hard palate, and bilateral ear canals. UPDATE: Derm feels strongly that this is a herpetic rash!!

Approach to Hemoptysis:

  1. Is it really hemoptysis?
  2. Massive vs. not-massive – definitions vary tremendously by source. Greater than 300cc in 24 hours relatively well accepted.
    1. Airway protection! Patients with massive hemoptysis are at greater risk of asphyxiation than bleeding out.
  3. Big categories:
    1. Infectious
    2. Malignancy
    3. Inflammatory
    4. Other: ** often forgotten – pulmonary edema! Hemosiderin-laden macrophages with pulm edema from heart failure can appear pink or bloody **

Oral-cutaneous vesicular rashes

  • Can’t miss SJS/TEN!


    • Infection
      • Herpes
      • Zoster
      • Coxsackie – hand foot and mouth
      • Atypical infection with reaction (mycoplasma, legionella)
    • Other drug reactions
      • Erythema multiforme
    • Inflammatory/Autoimmune
      • IBD
      • Behcets
      • SLE
      • Pemphigous vulgaris
      • Bulous pemphigoid
      • Bullous impetigo
      • Kawasaki
    • Other:
      • Niacin deficiency

Finally, thanks to Jesse for presenting a mini-EKG case of a patient with grouped beating and sinus bradycardia felt to be 2/2 to mobitz 1 sinus exit block vs. mobitz 2 AV block à with p waves possibly buried in the t-wave identified by HH of course – every ID doc has his Cards day!!

–>There a good summary (below) of SA and other Blocks on Life in the Fast Lane! 

First Degree SA block

= Delay between impulse generation and transmission to the atrium.

  • This abnormality is NOT detectable on the surface ECG.= Progressive lengthening of the interval between impulse generation and transmission, culminating in failure of transmission.

Second Degree SA block, Type I (Wenckebach)

  • The gradually lengthening transmission interval pushes successive P waves closer together.
  • This results in grouping of the P-QRS complexes.
  • Pauses due to dropped P waves occur at the end of each group.
  • The P-P interval progressively shortens prior to the dropped P wave.
  • This pattern is easily mistaken for sinus arrhythmia.= Intermittent dropped P waves with a constant interval between impulse generation and atrial depolarisation.

Second Degree SA block, Type II

  • This pattern is the equivalent of Mobitz II.
  • There is no clustering of P-QRS complexes.
  • Intermittent P waves “drop out” of the rhythm, while subsequent P waves arrive “on time”.
  • The pause surrounding the dropped P wave is an exact multiple of the preceding P-P interval.

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