NECROSIS

A necrotic area in a patient with calciphylaxis.
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This page deals with the patient who presents with one or more large necrotic lesions. Different from this is the patient with palpable purpura. The two broad categories causing necrosis of the skin are infection and vasculitis.

Workup

Skin Biopsy

For the acutely-ill patient with necrotic skin lesions, it is important to exclude septic emboli (e.g. Neisseria, Staph, RMSF, Strep, Pseudomonas, Candida). A skin biopsy (usually punch) with special stains for bacteria, fungi and AFB is in order. Sending another skin specimen for bacterial, fungal and AFB culture should also be done. One may aspirate tissue fluid from an early lesion for gram stain and culture.

Laboratory

Typical blood work for patients with necrotic skin lesions may include CBC with peripheral eosinophil count (Churg-strauss syndrome), creatinine, LFT's, RF, ASO, ANA, ANCA, SPEP (Hypergammaglobulinemic purpura), Hepatitis B and C, ELISA for parvovirus B19, complement levels, cryoglobulins, antiphospholipid antibody, anti-neutrophil cytoplasmic antibody, PT, PTT, protein C, protein S, cryoglobulins, fibrin split products, anti C1Q antibody and IgA-fibronectin aggregates (if available).

Other potential laboratory studies include CXR, stool guiac and urine analysis,

For patients with chronic renal failure on dialysis include parathyroid hormone, phosphorus, and calcium (rule out calciphylaxis).

Adult

Anthrax
Antiphospholipid-antibody syndrome
Aspergillosis, primary cutaneous
Brown recluse spider bite
Calciphylaxis
Fluoroscopy-Induced Skin necrosis (AD 2003;139;140)
Calcium chloride, cutaneous contact
Cholesterol Emboli
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Churg-Strauss Syndrome
Coma, sweat gland necrosis
Coumadin necrosis
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Cowpox
Cryoglobulinemia
Purpura fulminans - Disseminated Intravascular Coagulation
Ecthyma gangrenosum
Nicolau Syndrome
Heparin Necrosis
Hyperoxaluria
Infections, various, e.g. fungal.
Necrotizing fasciitis. Warm induration of a portion of a limb followed by dusky or violaceous discoloration, then bulla formation and necrosis is characteristic.
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Septic Emboli
Streptococcal toxic shock-like syndrome
Vasculitis (any): Photograph courtesy Michael O. Murphy, MD
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Vibrio vulnificus

HIV

Above plus

Endothelial dysfunction thrombosis in hiv positive patients may be caused by increased antiphospholipid antibodies and decreased protein s as part of general endothelial cell dysfunction. J of aids 1992;5;484

Cytomegalovirus Viremia

Digital infarcts occurred in two HIV-1-infected patients with CMV viremia.

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