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Autoimmune disorder against hemidesmosomes
2%
5/279
S. aureus infection
7%
19/279
B. anthracis infection
82%
229/279
Squamous cell carcinoma
4%
10/279
Basal cell carcinoma
5%
13/279
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This patient has a necrotic skin wound with surrounding black eschar, classic for cutaneous anthrax infection. Farmers working with livestock are at increased risk of the disease. Bacillus anthracis is a Gram-positive bacillus, spore-forming organism. B. anthracis can cause a cutaneous disease (as in this patient) generally via contact with infected animals or a pulmonary disease via inhalation of spores. The pulmonary form of the disease presents with pulmonary hemorrhage and mediastinitis, and has near complete mortality if untreated. B. anthracis possess two virulence factors, lethal factor and edema factor, which are central to its pathogenesis. Simmons discusses the cutaneous form of anthrax. B. anthracis is found in many hoofed animals, which serve as a disease reservoir. The cutaneous form of anthrax occurs following subcutaneous inoculation of spores. There is an incubation period of approximately one week prior to the appearance of a painless red papule which rapidly enlarges. The papule eventually progresses to a necrotic ulcer with black eschar. Kamal et al. discuss the treatment of B. anthracis infection. Antimicrobial therapy dramatically improves survival and include penicillin, ampicillin, ciprofloxacin, doxycyline, clindamycin, and clarithromycin, among others. However, bacterial sensitivity to antibiotics should be tested once diagnosis is confirmed. It is currently recommended to continue therapy for 60 days. A vaccine is also available for patients deemed to be at high risk. Figure A depicts cutaneous anthrax. Note the necrotic center with surrounding eschar. Incorrect Answers: Answer 1: Bullous pemphigoid is an autoimmune disorder with antibodies against hemidesmosomes. It presents with bullae. Answer 2: S. aureus infection can cause impetigo. Impetigo presents with honey-colored crusts. Answer 4: Squamous cell carcinoma presents with an ulcerative red lesion usually with scale. Answer 5: Basal cell carcinoma presents with a pink, pearly nodule with rolled borders and telangiectasias.
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