Cutaneous Emergencies

1
Cutaneous Emergencies

• Joe Lex, MD, FAAEM
• Department of Emergency Medicine
• Temple University Hospital
• Philadelphia, PA

2
Topics Covered

• Cancers of the Skin
• Decubitus Ulcer
• Dermatitis
• Infections / Systemic Illnesses
• Maculopapular Lesions
• Vesicular / Bullous Lesions

3
Winner Ugly Dog Contest
4
1. Cancers of the Skin

• Basal cell carcinoma
• Kaposis sarcoma
• Melanoma
• Squamous cell carcinoma

5
Basal Cell Carcinoma

• Nodular
• Ulcerating
• Sclerosing (cicatricial)
• Superficial, pigmented
• Danger zones midface, behind ears
• Refer to dermatologist

Cancers
6
Basal Cell Carcinoma
Nodular
Pigmented
Ulcerating
7
Basal Cell Carcinoma
8
Kaposis Sarcoma

• Painless, raised brown-black or purple papules
  and nodules that do not blanch
• Face, chest, genitals, and mouth
• Not associated with increased morbidity or
  mortality
• Referral if bothersome

Cancers
9
Kaposis Sarcoma
HIV-associated homosexual men
Cancers
Classic KS elderly male Ashkenazi and
Mediterranean Jews
10
Melanoma RISK

• Risk factors
• Moles atypical or common
• Red hair and freckling
• Inability to tan
• Sunburn severe sunburn especially before age 14
• Kindred family history

Cancers
11
Melanoma
Cancers
Melanocytic nevus
Melanoma in situ
Superficial spreading melanoma
12
Melanoma

• Early detection early cure
• Have low threshold, refer if suspected

Cancers
13
Squamous Cell Carcinoma

• Sunlight exposure
• Age gt55
• Men gt women
• White gt Black

Cancers
14
Squamous Cell Carcinoma

• Treatment
• Surgery
• Radiotherapy
• Cryotherapy
• 5-fluorouracil
• 90 cure rate if treated early

Cancers
15
2. Decubitus Ulcer

• External compression of dermis and hypodermis ?
  ischemic tissue damage and necrosis
• Risk factors inadequate nursing care, diminished
  sensation / immobility, hypotension, fecal /
  urinary incontinence, low serum albumin, poor
  nutrition

Decubitus
16
Stages of Ulcers

• I Nonblanching erythema of intact skin

Decubitus
II Necrosis, superficial or partial-thickness
involving epidermis and/or dermis. Bullae ?
necrosis of dermis (black) ? shallow ulcer
17
Stages of Ulcers

• III Deep necrosis, crateriform ulceration,
  full-thickness skin loss extends to, but not
  through, fascia

Decubitus
18
Stages of Ulcers

• IV Full-thickness ulceration with extensive
  damage / necrosis to muscle, bone, support
  structures

Decubitus
19
Management

• Stage I and II topical antibiotics under moist
  sterile gauze
• Stage III and IV surgical debridement and repair
• Complications osteomyelitis, sepsis with
  resistant organisms (VRE, MRSA, etc.)

Decubitus
20
3. Dermatitis

• Atopic
• Contact
• Eczema
• Psoriasis
• Sebaceous cysts
• Seborrhea

Dermatitis
21
Atopic Dermatitis Eczema

• Itching ? rubbing and scratching ?
  lichenification (hyperplasia)
• Diagnosis based on clinical findings
• Serum IgE level usually elevated
• Associated with allergic rhinitis, asthma

Dermatitis
22
Atopic Dermatitis Treatment

• Fraught with problems
• Dependence on glucocorticoids ? atrophy,
  tachyphylaxis, hypertrichosis

Dermatitis
23
Atopic Dermatitis
Dermatitis
24
Atopic Dermatitis
Dermatitis
25
Atopic Dermatitis
Nummular eczema
Dermatitis
Dyshidrotic eczema
26
Contact Dermatitis

• Generic term applied to acute or chronic
  inflammatory reactions to substances that come in
  contact with the skin
• Chemical irritant
• Allergic caused an antigen that elicits a type IV
  (cell-mediated or delayed) hypersensitivity
  reaction

Dermatitis
27
Contact Dermatitis
Dermatitis
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Contact Dermatitis

• Prevention
• Wear protective clothing
• If contact occurs, wash with water or weak
  neutralizing solution
• Barrier creams

Dermatitis
29
Contact Dermatitis

• Gauze soaked in Burows solution changed every 2
  to 3 hours
• Class I topical corticosteroid preparations may
  be effective if nonexudative, nonbullous
• Systemic corticosteroids if severe (cannot
  function or sleep) or for exudative lesions

Dermatitis
30
Burows Solution

• Aluminum acetate in water
• Invented by ophthalmologist Karl August Burow
  (1809 1874)

Dermatitis
31
Topical Corticosteroids

• Class 1
• Very potent (up to 600 times as potent as
  hydrocortisone)
• Clobetasol propionate
• Betamethasone dipropionate

Steroids
32
Topical Corticosteroids

• Class 2
• Potent (I50-100 times as potent as
  hydrocortisone)
• Betamethasone valerate/dipropionate
• Diflucortolone valerate
• Fluticasone valerate
• Hydrocortisone 17-butyrate
• Mometasone furoate
• Methylprednisolone aceponate

Steroids
33
Topical Corticosteroids

• Class 3
• Moderate (2-25 times as potent as hydrocortisone)
  
• Aclometasone dipropionate
• Clobetasone butyrate
• Fluocinolone acetonide
• Triamcinolone acetonide

Steroids
34
Topical Corticosteroids

• Class 4
• Mild
• Hydrocortisone 0.5-2.5

Steroids
35
Psoriasis
Dermatitis
36
Psoriasis
Dermatitis
37
Psoriasis Findings

• Bilateral, often symmetrical often spares
  exposed areas favors elbows, knees, scalp, and
  intertriginous areas face involvement uncommon
• Guttate psoriasis disseminated small lesions
  without predilection of site

Dermatitis
38
Psoriasis Locations
Dermatitis
39
Psoriasis Treatment

• Remove scales soak in water
• Topical fluorinated glucocorticoid ointment to
  wet skin (betamethasone valerate, fluocinolone
  acetonide, et al.)
• Cover with plastic wrap, leave overnight

Dermatitis
40
Sebaceous Cyst

• Synonyms wen, infundibular cyst, epidermal cyst
• Most common cutaneous cyst
• Origin epidermis or hair follicle epithelium
• Fills with keratin, lipid-rich debris
• Rupture common

Dermatitis
41
Sebaceous Cyst

• Treatment drainage if infected
• Removal by surgeon

Dermatitis
42
Seborrheic Dermatitis

• Cradle cap in infants
• Pityriasis sicca dandruff

Dermatitis
43
Seborrheic Dermatitis

• Yellowish-red or gray-white skin,
• Often greasy or scaling macules and papules
• Varying size 5 to 20 mm

Dermatitis
44
Seborrheic Erythroderma

• Frightened, red, toxic patient
• Skin red, thick, scaly
• Many drugs, illnesses implicated
• Can lead to high-output failure
• Admit to warm room with blankets
• Glucocorticoids, emollients

Dermatitis
45
Seborrheic Erythroderma

• Seborrheic erythroderma diarrhea failure to
  thrive Leiners disease
• Associated with immunodeficiency disorders

Dermatitis
46
Seborrheic Erythroderma
Dermatitis
47
Seborrheic Erythroderma
Dermatitis
48
4. Infections

• Bacterial
• Fungal
• Parasitic
• Viral
• Systemic

49
Bacteria
50
Abscess

• Abscess collection of pus with inflammation,
  tissue destruction
• Furuncle deep-seated, red, hot, tender abscess
  that evolves from staphylococcal folliculitis
• Carbuncle deeper infection, interconnecting
  abscesses

Bacteria
51
Abscess
Furuncle
Bacteria
Abscess
Carbuncle
52
Abscess

• Cause Staphylococcus aureus
• Treatment incision and drainage /- antibiotic

Bacteria
53
Hidradenitis Suppurativa

• Chronic, suppurative disease of apocrine
  glandbearing skin in axillae and anogenital
  region
• Tender, red nodules not related to hair follicles
• Acute lesions incise and drain
• Refer for definitive care

Bacteria
54
Hidradenitis Suppurativa
Bacteria
55
Cellulitis and Erysipelas

• Acute, spreading infections of dermal and
  subcutaneous tissues
• Red, hot, tender skin, often at site of bacterial
  entry
• Cause group A beta-hemolytic streptococci or
  Staphylococcus aureus

Bacteria
56
Cellulitis and Erysipelas

• Treatment outpatient
• Dicloxacillin
• Macrolide EES, azithromycin, clarithromycin
• Amoxicillin-clavulanate
• Clindamycin
• TMP-SMZ

Bacteria
57
Cellulitis Erysipelas
Bacteria
58
Cellulitis
Bacteria
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Cellulitis

• Facial cellulitis in child ? consider Haemophilus
  influenzae

Bacteria
60
Impetigo and Ecthyma

• Superficial infection of epidermis by
  Staphylococcus aureus and Streptococcus pyogenes
• Extension into dermis ? ecthyma, crusted erosions
  or ulcers

Bacteria
61
Impetigo and Ecthyma
Bacteria
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Impetigo, Nonbullous

• Transient superficial small vesicles or pustules
  rupture ? erosions ? golden-yellow crust (often
  seen, not pathognomonic)

Bacteria
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Impetigo, Bullous
Bacteria
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Impetigo, Ecthyma
Bacteria
65
Impetigo Treatment

• Topical mupirocin (Bactroban) highly effective
  against GAS and Staph (including MRSA)
• Systemic antimicrobials penicillin,
  dicloxacillin, erythromycin, minocycline (for
  MRSA)

Bacteria
66
Necrotizing Infections

• Group A streptococcal gangrene
• Cellulitis ? dusky blue ? bullae or vesicles
  (yellow ? red-black fluid) ? rapid spread along
  fascial planes ? necrotic slough
• Treatment early extensive debridement, high-dose
  antibiotic

Bacteria
67
Necrotizing Infections
Bacteria
68
Necrotizing Infections
Bacteria
69
Necrotizing Infections
Bacteria
70
Necrotizing Infections
Bacteria
71
Fungus
72
Candida

• Candidosis, moniliasis
• Candida albicans, others
• Intertrigo
• Interdigital
• Diaper dermatitis

Fungus
73
Candida Intertrigo
Fungus
74
Candida
Fungus
75
Candida Thrush
Fungus
76
Candida Angular Stomatitis
Fungus
77
Candida Treatment

• Nystatin (Mycostatin) tablets or suspension
  100,000 units QID
• Clotrimazole (Lotrimin)
• Fluconazole (Diflucan)
• Itraconazole (Sporanox)
• Ketoconazole (Nizoral)
• Voriconazole (Vfend)

Fungus
78
Tinea
Epidermal dermatophytes

• Tinea pedis
• Tinea manuum
• Tinea cruris
• Tinea corporis
• Tinea facialis
• Tinea capitis

Fungus
79
Tinea
Fungus
80
Tinea Diagnosis

• Potassium hydroxide microscopic identification of
  septated, tubelike structures and spores

Fungus
81
Tinea Treatment

• Skin topical antifungals
• Hair and nails oral preparations
• Griseofulvin possible elevated transaminases

Fungus
Gray patch tinea capitis
82
Tinea Treatment
Fungus
Kerion do not I D
83
Parasites
84
Pediculosis

• Head lice
• Body lice
• Pubic lice

Parasite
85
Pediculosis Treatment

• Permethrin cream 5 (Elimite)
• OTC Permethrin 1 (Nix)
• Pyrethrins (RID)
• Lindane 1 shampoo (Kwell)
• Seizures, aplastic anemia
• Malathion 0.5 in 78 isopropyl alcohol (Ovide)

Parasite
86
Scabies

• Undiagnosed scabies Seven-Year Itch
• Mite Sarcoptes scabiei
• Extremely itchy
• Diagnosis burrows or scabies prep (shave lesion,
  magnification)

Parasite
87
Scabies
Parasite
88
Scabies
Parasite
89
Scabies

• Permethrin 5 cream (Elimite) or lindane 1
  lotion (Kwell)
• Leave on overnight, rinse off in morning
• Lindane easier to apply, less expensive, but some
  resistance
• Lindane neurotoxic to infants

Parasite
90
Botfly
Parasite
91
Virus
92
Viral Infections

• Aphthous ulcer
• Erythema infectiosum
• Herpes simplex
• Herpes zoster
• Human papillomavirus (HPV)
• Molluscum contagiosum
• Warts

Virus
93
Aphthous Ulcer

• Canker sore
• Painful shallow ulcer covered with fibrin
• Adenopathy common

Virus
94
Aphthous Ulcer

• Differential
• Behçet's
• Herpes
• Treatment
• Symptomatic
• Topical steroids and analgesics

Virus
95
Erythema Infectiosum

• Fifth disease
• Parvovirus
• Fever, coryza, headache, malaise 2 days before
  rash
• No treatment

Virus
96
ID / Rash Trivia

• 1st disease rubeola (measles)
• 2nd disease scarlet fever
• 3rd disease rubella
• 4th disease toxin-producing staphylococcus
• 5th disease erythema infectiosum (parvovirus)
• 6th disease roseola

Virus
97
Herpes Simplex

• Herpes simplex
• Cold sore
• Fever blister
• Herpes labialis
• Herpes gladiatorum
• Scrum pox
• Whitlow

Virus
Tzanck preparation multi-nucleated giant
keratinocyte
98
Herpes Simplex
Virus
99
Herpes Simplex

• Antivirals more effective in primary infection
  than recurrence
• Acyclovir (Zovirax) 400 mg TID or 200 mg 5 times
  daily
• Valacyclovir (Valtrex) BID
• Famciclovir (Famvir) TID

Virus
100
Herpes Zoster

• Varicella Zoster Virus (VZV)
• Shingles
• Prodrome flu-like symptoms prior to rash
• Depression very common

Virus
101
Herpes Zoster
Virus
102
Herpes Zoster

• Herpes zoster ophthalmicus CNV
• Vision-threatening condition
• Hutchinson sign lesions on tip of nose ?
  nasociliary nerve
• Ramsay Hunt syndrome CNVII
• Facial palsy resembling Bell palsy
• Vesicles in ear canal or on tympanic membrane

Virus
103
Herpes Zoster
Virus
104
Human Papillomavirus

• Verruca vulgaris common warts
• Verruca plantaris plantar warts
• Verruca plana flat warts
• Epidermodysplasia verruciformis

Virus
105
Human Papillomavirus
Flat warts
Virus
Plantar warts
106
Human Papillomavirus

• Treatment conservative, since spontaneous
  remission is the rule
• Aggressive if symptomatic (e.g. plantar, genital)
• Podofilox 0.5 (Condylox) gel or solution BID x
  3 days ? no therapy x 4 days ? repeat up to 4
  cycles
• Cryotherapy

Virus
107
Molluscum Contagiosum

• Poxvirus ? umbilicated papules
• Normal host cosmetic problem, spontaneous
  remission
• Immunocompromised host require HAART (Highly
  Active AntiRetroviral Therapy) to avoid
  widespread dissemination

Virus
108
Molluscum Contagiosum
Virus
109
Systemic
110
Rocky Mountain Spotted Fever

• Only in Western hemisphere
• Highest US incidence Oklahoma, North Carolina,
  Virginia, Maryland
• Rarely in Rocky Mountains
• Incubation 3 to 14 days
• Prodrome anorexia, irritability, malaise,
  chills, fever

Systemic
111
Rocky Mountain Spotted Fever

• History of tick bite 60
• Onset abrupt fever (94), severe headache (86),
  myalgias especially back and legs (83)
• First illness day 14 have rash
• First 3 days 49 have rash.
• 13 ? no rash (spotless RMSF)

Systemic
112
Rocky Mountain Spotted Fever

• Early lesions 2 to 6 mm, pink, blanchable
  macules
• Evolve to deep red papules
• In 2 to 4 days hemorrhagic, no longer blanchable
• Rarely eschar

Systemic
113
Rocky Mountain Spotted Fever
RMSF papules
Systemic
RMSF macules
114
Rocky Mountain Spotted Fever
Hemorrhagic lesions
Systemic
115
Immune Thrombocytopenic Purpura

• ? production
• Drugs, aplastic
• ? destruction
• Drugs, TTP, infection
• Sequestration
• Spleen

Systemic
116
Immune Thrombocytopenic Purpura

• Common and early site palate
• Palatal petechiae also seen in
• strep throat
• mononucleosis
• rubella (measles)

Systemic
117
German Measles (Rubella)

• Young adults
• Droplet spread
• No prodrome
• 14 21 day incubation
• Lymph nodes /- arthralgias

Systemic
118
Measles (Rubeola)

• Droplet spread
• 10 15 day incubation
• URI, malaise, photophobia
• Koplik spots

Systemic
119
Chicken Pox (Varicella)

• 90 lt10 years old
• Incubation 10 23 days
• Prodrome uncommon
• Very itchy
• Dewdrop on a
• rose petal

Systemic
120
Janeway Lesions
Systemic
121
Oslers Nodes
Systemic
122
Lyme Borreleosis ECM
Systemic
123
Lyme Borreleosis ECM
Systemic
124
Lyme Borreleosis ECM
Systemic
125
Syphilis
Systemic
126
Eczema Herpeticum

• Eczema herpeticum
• Low-grade fever, tight skin
• Potentially lethal
• Acyclovir

Systemic
127
Eczema Herpeticum

• Eczema herpeticum
• Low-grade fever, tight skin
• Potentially lethal
• Acyclovir

Systemic
128
5. Maculopapular Lesions

• Erythema multiforme
• Erythema nodosum
• Henoch-Schönlein purpura (HSP)
• Pityriasis rosea
• Purpura
• Urticaria

129
Erythema Multiforme

• Idiopathic gt50
• Drugs sulfonamides, phenytoin, barbiturates,
  penicillin, allopurinol
• Infection HSV, mycoplasma

Mac Pap
130
Erythema Multiforme

• Malaise, fever, myalgias, arthralgias
• Pruritus or burning can occur before skin lesions
  develop
• Multiforme lesions, target most familiar

Mac Pap
131
Erythema Multiforme
Mac Pap
132
Erythema Multiforme
Mac Pap
133
Erythema Multiforme

• Systemic steroids symptomatic relief, but dont
  change duration or outcome
• Extensive disease or mucous membranes involvement
  ? hospitalize in ICU or burn unit
• Eye involvement ophthalmology

Mac Pap
134
Erythema Nodosum

• Inflammatory / immunologic reaction of panniculus
• Painful nodules on lower legs
• Multiple and diverse causes

Mac Pap
135
Erythema Nodosum

• Treat underlying cause (e.g., stop medicine)
• Symptomatic relief bedrest, elevation, NSAIDs

Mac Pap
136
Henoch-Schönlein Purpura

• Hypersensitivity vasculitis
• Primarily children
• 75 recent URI with group A streptococcus

Mac Pap
137
Henoch-Schönlein Purpura

• Palpable purpura
• Bowel angina abdominal pain worse after meal
• Bowel infarct
• Renal failure
• Arthritis

Mac Pap
138
Henoch-Schönlein Purpura

• Self-limiting
• Admit for pain control, blood loss, hydration,
  renal monitoring
• If well-appearing, outpatient

Mac Pap
139
Pityriasis Rosea

• Acute eruption, self-limited course
• Herald plaque on trunk
• Generalized secondary eruption 1 or 2 weeks later
• Christmas tree pattern
• Spontaneous remission in 6 weeks without therapy

Mac Pap
140
Pityriasis Rosea
Mac Pap
141
Pityriasis Versicolor
Mac Pap
142
Purpura Fulminans

• Fever, shock, multiorgan failure, rapid
  development hemorrhagic skin necrosis
• Vascular collapse disseminated intravascular
  coagulation (DIC) dermal vascular thrombosis

Mac Pap
143
Purpura Fulminans
Mac Pap
144
Purpura Fulminans
Mac Pap
145
Purpura Fulminans
Mac Pap
146
Purpura Fulminans
Mac Pap
147
Urticaria and Angioedema

• Urticaria wheals ? transient edematous papules
  and plaques, usually pruritic, due to edema of
  papillary body
• Angioedema larger edematous area involving
  dermis and subcutaneous tissue

Mac Pap
148
Urticaria
Mac Pap
149
Urticaria
Mac Pap
150
Urticaria
Mac Pap
151
Urticaria

• Urticaria hives
• Cutaneous IgE-mediated
• Treatment
• Epinephrine antihistamines /- steroids
• H2 receptor blocker if severe
• Cool compresses soothing
• Refer to allergy specialist

Mac Pap
152
Angioedema

• Angioedema of tongue, lips, face in 0.1 to 0.2
  of patients taking ACE-inhibitor
• Management supportive, special attention to
  airway
• Usual allergic-reaction drugs not proven
  beneficial

Mac Pap
153
Angioedema
Mac Pap
154
Angioedema
Mac Pap
155
Angioedema
Mac Pap
After attack
During attack
156
6. Papular/Nodular Lesions

• Hemangioma / Lymphangioma
• Lipoma

157
Hemangioma

• Benign vascular proliferations
• Regress without therapy

158
Lymphangioma

• Multiple small fluid-filled vesicles
  (frog-spawn)
• Present at birth or appears in infancy or even in
  childhood
• No spontaneous regression

159
Lipoma

• Benign subcutaneous tumor
• Soft, rounded, or lobulated
• Movable against overlying skin
• May become large
• Composed of fat cells

160
6. Vesicular/Bullous Lesions

• Pemphigus vulgaris
• Staphylococcal scalded skin syndrome
• Stevens Johnson syndrome
• Toxic epidermal necrolysis

Bullous
161
Nikolskys Sign

• Epidermis dislodged by gentle finger stroke near
  blister
• Pressure on blister ? lateral extension of
  subdermal fluid

Bullous
162
Pemphigus Vulgaris

• Autoimmune, often fatal
• Age 40 to 60
• Treatment high-dose steroids
• Other immunosuppression azathioprine,
  cyclophosphamide, plasmapharesis, methotrexate,
  etc.

Bullous
163
Pemphigus Vulgaris
Bullous
164
Pemphigus Vulgaris
Bullous
165
S.S.S.S.

• Staphylococcal scalded skin syndrome Ritters
  disease
• Toxin-mediated epidermolysis
• Bullous impetigo with generalization ?
  scarlatiniform syndrome ? generalized
  scalded-skin syndrome

Bullous
166
S.S.S.S.

• Erythroderma ? exfoliation ? desquamation ?
  recovery
• Tender erythema
• Positive Nikolskys (?)
• Spares mucous membranes
• Treatment anti-staphylococcal antibiotic,
  rehydration

Bullous
167
S.S.S.S.
Bullous
168
S.S.S.S.
Bullous
169
Stevens-Johnson / T.E.N.

• Stevens-Johnson syndrome Erythema Multiforme
  Major
• Toxic epidermal necrolysis TEN Lyells
  disease
• Drug-induced or idiopathic
• Skin tenderness and erythema
• Extensive cutaneous and mucosal exfoliation

Bullous
170
Stevens-Johnson / T.E.N.

• 80 drug related
• Sulfa drugs sulfadoxine, sulfadiazine,
  sulfasalazine, cotrimazole
• Allopurinol
• Carbamazepine

• Hydantoins
• Phenylbutazone
• Piroxicam
• Chlormezanone
• Amithiozone
• Aminopenicillins

Bullous
171
Stevens-Johnson / T.E.N.

• Prodrome fever, flu-like symptoms 1 to 3 days
  prior to mucocutaneous lesions
• Mild to moderate skin tenderness
• Positive Nikolskys
• Conjunctival burning or itching

Bullous
172
Stevens-Johnson / T.E.N.
Bullous
173
Stevens-Johnson / T.E.N.
Bullous
174
Stevens-Johnson / T.E.N.
Bullous
175
Stevens-Johnson / T.E.N.

• High mortality dehydration and infection
• ICU vs. burn unit

Bullous
176
and finally
177
Delusional Parasitosis

• Suffered from infestation for long time
• Seen by numerous physicians, exterminators,
  parsitologists, hygienists and entomologists
• Consistently and fiercely reject negative
  findings or any that deviate from their
  perceptions

Imaginary
178
Delusional Parasitosis

• 4. Matchbox sign"
• Containers of dust, lint, skin scrapings, toilet
  paper, dried blood or scabs, hair or other pieces
  of human tissue
• Self mutilation ranging from scratches to deep
  ulceration
• From attempting to dig out bugs

Imaginary
179
Delusional Parasitosis

• 6. One or more family members may share delusion
• Folie à deux / Folie à trois
• Use of home remedies, distrust of prescription
  drugs
• Self exposure to often dangerous levels of
  pesticides

Imaginary
180
Delusional Parasitosis

• Similar to cocaine bugs
• Patient feels parasites crawling under his skin
• Also associated with high fever, extreme alcohol
  withdrawal
• Often associated with visual hallucinations of
  insects

Imaginary
181
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