Case for Diagnosis

Presented by Choon Siew Eng FRCP, Johor Bahru, Malaysia.

46 years old woman with 3-year history of gradually enlarging asymptomatic indurated plaques on her neck, both axillae right side of abdomen, right groin and lower back. She is otherwise well with good general health. There was no significant family history.

Physical examination revealed multiple indurated erythematous to hyperpigmented plaques on right side of her neck, right flank, both groins and axillae. The overlying skin is atrophic with brownish adherent scales.
There were multiple groups of hyperpigmented papules on abdomen, upper thighs and legs. Some papules appeared yellowish. Palms, soles, nails, scalp and mucosae are spared.

I am thinking of treating her as sarcoidosis since she is distressed by her extensive lesions
Differential Diagnoses: Nodular amyloidosis, Scleromyxoedema, Morphoea, xanthogranuloma

Repeated blood tests such as full blood count,BUSE, LFT, thyroid functions, serum and urine calcium and autoimmune screening were normal. Her ESR was also normal . CXR was normal and Mantoux test was negative.Sputum for AFB X3 negative. Biopsy from abdominal lesion showed numerous granulomata composed of epithelioid histiocytes, lymphocytes and multinucleated giant cells, Langhan’s type. Special stains for Acid fast bacilli (ZN, Wade fite) and fungal bodies (PAS) were negative. No abnormal deposits of eosinophilic amorphous material seen. No foreign body seen by polarised light.

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Case For Diagnosis

Presented by Dr. Amanda Oakley, Hamilton, New Zealand

A month ago, a 14-year old girl presented to the paediatricians with a fever, arthralgia and small purpuric and possibly target-like spots on her legs. She had been previously well and had taken no medications. After extensive negative investigation she was commenced on penicillin in case she had bacterial endocarditis, and was sent home.
She was readmitted yesterday with on-going fever and arthralgia, and crops of extremely painful plaques mainly affecting her face. Earlier lesions on her abdomen and limbs have resolved leaving marked hypo-hyperpigmentation or scarring. Biopsy of the plaque on her neck shows full thickness necrosis histologically with little inflammation. EM-like. Several new plaques have been observed to arise overnight despite an initial dose of prednisone 40mg. There is no mucosal involvement to date.
All tests so far negative - we are thinking up some more tests but we don't know the correct diagnosis. No other drugs as far as we can ascertain.
Has anyone seen anything like this? Is it erythema multiforme? Other possible diagnosis? Treatment?

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Case for Diagnosis

The patient is a 54 yo woman with a 2 week history of a rash on the arms and chest. Two months ago, she had erythema nodosum with atypical features (on her legs). The work-up eventually discovered Crohn's disease. She was started on Asacol around a month ago and around 2 weeks ago developed erythematous papules on arms and anterior chest.

0/E: The new lesions are 6 - 8 mm in diameter erythematous papules with the suggestion of central punctae. The E.N. has resolved.

Lab: Representative lesions were biopied.

Question: What are your thoughts? We will post pathology in around a week.

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Continuous Medical Education

VGRD and this VGRD Blog have been around for a number of years now. Both serve as forums at which dermatologists and other physicians can post and comment on interesting and challenging cases. Other sites such as the Skin Cancer Clinic blog out of Queensland, Australia serve a similar function and are better attended. We came across an article recently which lends credence to this activity and indicates that this interactive format may be a better way of providing continuing professional education than the lectures which we traditionally attend at conferences and hospital rounds.

The article appeared in The Journal of General Internal Medicine in 2004. Here are the particulars:

Toward Continuous Medical Education
Roni F Zeiger, MD
Gen Intern Med. 2005 January; 20(1): 91–94.
For full article click on PDF locate .pdf download access it.

While traditional continuing medical education (CME) courses increase participants' knowledge, they have minimal impact on the more relevant end points of physician behavior and patient outcomes. The interactive potential of online CME and its flexibility in time and place offer potential improvements over traditional CME. However, more emphasis should be placed on continuing education that occurs when clinicians search for answers to questions that arise in clinical practice, instead of that which occurs at an arbitrary time designated for CME. The use of learning portfolios and informationists can be integrated with self-directed CME to help foster a culture of lifelong learning.

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Thorny, Horny Dilemma

Ian McColl from Queensland, Australia, is presenting a five year-old girl for opinions. He doesn't have much information at this time. We will present her case formally on VGRD in a week or two, but I know he'd appreciate rapid responses at this time, too.

Ian writes:
"She had been seen elsewhere for treatment of her "severe psoriasis" which she had for the last two years. Clinically this is chronic mucocutaneous candidiasis. There is no family history. She has had vaginal candidiasis before and UTIs. She is otherwise well. She did have shotty glands in neck, groin and axillae.

Has anyone had recent experience of treating a case? Ketoconazole orally ? toxicity? Fluconazole orally? How long for? Best wishes, Ian."

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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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