Case from Inuvik

From Alex Wong, PGY II Internal Medicine, UAB, Calgary:
I'm currently on a rotation up in the Northwest Territories and I just came back from a three-day travel clinic in Inuvik. We were asked to consult on a 40 yo woman who essentially has wide-spread rash. Was wondering whether you guys had any ideas.
Hx and O.E: Sudden-onset maculopapular pruritic rash on the trunk (both front + back) and upper extremities including hands, no obvious triggers or contacts according to the GP. Tried steroid cream + Benadryl with no effect, used Prednisone and cleared almost immediately. Took the Prednisone away and immediately came back, so restarted the Prednisone a second time and tried to taper off slowly this time... again, when Prednisone was taken away, rash came back (although during taper apparently she didn't have any symptoms.
Biopsy:They got a skin biopsy, and unfortunately don't remember the exact details of the biopsy (sorry), except that it raised the possibility of SLE.
Lab: GP did ANA, which was positive. Subsequently did C3/C4 + dsDNA, which were negative.
Steroids being slow-tapered again, and she had no rash when I saw her yesterday afternoon. She works on/off as hotel housekeeper, but insists no new contacts / cleaning products.
Your thoughts would be greatly appreciated.

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'Tis the Season

A 78 yo man with a history of non-melanoma skin cancer presented today for a general skin exam: a six month check-up. It is high spring now and everyone is outdoors doing something. On his left mid-back I spied this unusual "tumor." The patient was unaware of it. He was pruning apple trees two days ago.



If he hadn't come in for a routine exam, who knows when this would have been discovered.

I pulled the tick out with forceps, gave him 200 mg of doxycycline to take and will see him back as necessary.

Strange and stranger. What some call an "incidentaloma."

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Positive Band Aid Sign

Most of us use the term "Positive Band Aid Sign." Let's call it PBAS
PUBMED has no articles on this entity and Google only had one or two hits.

I've seen three PBASs in the past week. What do you think of them? What lesions would you guess underlie the bandaids.


1. 72 yo woman with one month history of a lesion on upper lip



















2. 22 yo woman with 3 month history of lesion on arm
















3, 93 yo woman with one month history of lesion on arm

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Palm Pense-Bête

You may remember La Maladie du Petit Papier which was reported here on January 27th. Today, Twentysomething Generation's equivalent emerged.

I propose calling it: La Maladie du Palm Pense-Bête. This was brought in by a 24 yo woman. Will the ingenuity of our patients never cease? "O brave new world [electronic]!"

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Dermatomyositis -- New York Times

An interesting article appeared in the New York Times today on myositis. It is well-written and researched. You will benefit from and also enjoy perusing it. In addition, your patients will read it and may bring it to your attention.

March 27, 2007
An Elusive Diagnosis, and One That Comes With a Risk of Cancer

By RONI CARYN RABIN

To read the article click on Permalink

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Is Treatment Worse Than Disease?

The patient is a 48 yo woman with many actinic keratoses on face and chest. After discussing therapeutic options, she elected to use fluouracil cream. She was started on nightly 5% 5FU cream and at two weeks was noted to have a moderate inflammatory response. The 5FU was continued. By 23 days, I got an email indicating that she wasn't sleeping and was very concerned. I had her come in and the pictures speak for themselves.

I stopped the 5FU, placed her on cold compresses b.i.d. and desonide cream. Ambien 5 mg was given for sleep since she had not slept well for 4-5 nights and requested a soporific.






















1) What would you have done differently?
2) Is this a good argument for PDT?

One Year Follow-up

The patient still does not feel she is perfect. However, her skin looks great and she has virtually no AKs.

Your comments will be appreciated.

Dave Elpern

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Infant with Scalp Mass

The patient is a twenty-week-old infant with a scalp mass present for 2-3 months. It appears to be growing slowly. He was seven weeks premature; but otherwise all milestones have been normal. He had a type one intracranial bleed post partum but it was not complicated. He did have scalp vein IVs whilst in hospital, but it's unclear where they were.

The examination shows a 4x2.5 cm in diameter freely movable mass on the left parietal area. It feels firm. Skin and hair normal over it (in the photo it the hair looks a bit sparser over the lesion). Ultrasound was done and was interpreted as normal.



The mass looks benign. Do you have any suggestions about what this might represent and what to do at this point? Skull x-ray and CT may be indicated, however, I thought I'd get some opinions first.

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