title: Hemorrhagic bullae are not only skin deep.
abstract: BACKGROUND
  Dermatologic complaints are common presentations in the ED. Hemorrhagic bullae are an example of dermatologic manifestation caused by variable etiologies. The life-threatening skin lesion usually is an external sign of a systemic or immune response stimulated by an infection, toxin, medication, or disease process. Although most patient with life-threatening skin lesion, such as hemorrhagic bullae, may appear ill, patients who present in the early course of illness may appear well but deteriorate rapidly. For greater comprehension of hemorrhagic bullae, we prospectively followed 42 patients who presented with hemorrhagic bullae at the ED and analyzed their clinical characteristics and their confirmative diagnoses.
  
  
  METHODS
  This is a prospective, observational cohort study conducted at a university-affiliated community hospital. Data were collected from January 2002 to January 2007. Patients presenting to the ED with hemorrhagic bullae were enrolled prospectively.
  
  
  RESULTS
  All of our patients with hemorrhagic bullae had evidence of a serious disease: necrotizing fasciitis (42 case, 100%). The most common comorbidity was diabetes mellitus (18 cases; 42.9%). Vibrio species was the most common organism from blood culture (8/16 cases) and wound culture (17/27 cases). Streptococcal species was found in only 1 patient via blood culture and 4 patients via wound culture. The yield of positive wound culture with Vibrio species was significantly greater than with streptococcal species (P < .05). Fourteen (33.3%) patients came to the ED for help 48 hours later after the onset of hemorrhagic bullae. None of these 14 patients died. In our total of 42 patients, 8 (19%) died.
  
  
  CONCLUSIONS
  In our study, the most common causative disease of hemorrhagic bullae was necrotizing fasciitis. Hemorrhagic bullae are a more common clinical feature in Vibrio infection than in streptococcal infection. Hemorrhagic bullae may occur in the early stage of necrotizing fasciitis. Necrotizing fasciitis may be the first sign that emergency physicians come across in patients with hemorrhagic bullae that are not in the oral, genital, anal, ocular area, and high index of suspicion of Vibrio infection should be considered. More aggressive treatment may be needed as hemorrhagic bullae may occur in the early stage of a serious disease. Further multi-institution study may be required to support these findings.
authors: Department of Emergency Medicine, Chang Gung Memorial Hospital, Puzih City, Chiayi County 613, Taiwan.
authors: Cheng-Ting
authors: CT
authors: Hsiao
authors: Leng-Jye
authors: LJ
authors: Lin
authors: Chi-Jei
authors: CJ
authors: Shiao
authors: Kuaing-Yu
authors: KY
authors: Hsiao
authors: I-Chuan
authors: IC
authors: Chen
mesh_terms: D001768:Blister / Q000382:microbiology* / Q000401:mortality; D016009:Chi-Square Distribution; D015897:Comorbidity; D004636:Emergency Service, Hospital; D019115:Fasciitis, Necrotizing / Q000382:microbiology* / Q000401:mortality; D005260:Female; D006470:Hemorrhage / Q000382:microbiology* / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome