Does this ring a bell?

HPI: The patient is a 36 yo woman on home hemodialysis after a failed renal transplant for membraneous glomerulonephtritis who was referred by her rheumatologist for a "stat" skin biopsy. She sees the rheumatologist for amyloid nephropathy.

Shs is having the second episode of a painful erythematous eruption on the dorsum of the left foot. The first episode, two months ago, resolved after two weeks of Keflex and Bactrim.

Meds: Oxycontin, prednisone 20 mg daily, Keflex (x 4 days)

O/E: This is an upbeat but chronically ill woman. The pertinent findings are on the legs. There is dusky erythema on the dorsum of the left foot. In addition, there are petechaie on both lower extremities. She has a 2/6 pansystolic murmur which the rheumatologist feels is cardiac but her nephrologist feels radiates from her dialysis shunt (left arm).

Clinical Photos:




Labs: CBC: WBC 8900 normal differential. Creatinine 11.32 (normal < 1.2 mg%")
Biopsy: Performed today

Impression: Second episode of an erythematous process left foot. Although this was treated initially as "cellulitis" no real evidence of infection. This does not look infectious to me. I wonder about an embolic phenomenon. I know I have not seen this before.

Questions:
What is your presumptive diagnosis?
What more would you do at this time?
(On thinking about this patient, and the recurrence, the question of Fixed Drug Eruption arose. I will question her about intermittent prescription and OTC drug use.)

I will give F/U re: bx findings.

Read More

Post-Bypass Dermatitis

Presented by Professor Khalifa Sharquie

Baghdad, Iraq





HPI: A 58 year old patient developed sudden heart infarction that needed urgent bypass heart surgery in March of 2009. Left saphenous vein was used as graft. The patient was otherwise healthy apart from developed a rash on the left leg along the incision scar. The rash is nonpruritic and red in color ranging in size from pinpoint to 2 cm in diameter. This gradually enlarges in size and stop, then slowly resolves without therapy leaving residual pigmentation or scar within few weeks. The rash appear only on one side of the incision but never cross. The patient's medications include simvastatin and lisinopril therapy.



On examination: 2 red patches appeared 15 days ago. They were scaly and psoriasiform from about 1 cm to 2 cm in diameter. Within 2 days they started to resolve, losing their scales and becoming dusky red in color. In addition,there are numerous small varicosities along the legs and feet.



Biopsy could not be done for fear of developing a leg ulcer.

Lab: All investigations are normal including blood picture,ESR and biochemistry.



Clinical Photos:















Discussion: I have not seen any case similar to this patient. So I wonder if this is what has been rarely reported in the literature. (see reference) I am waiting my colleagues comments.



Reference:



Arch Dermatol. 1993 May;129(5):609-12.

Saphenous vein graft donor site dermatitis. Case reports and literature review. Hruza LL, Hruza GJ.Division of Dermatology, Washington University School of Medicine, St Louis, Mo.BACKGROUND--Coronary artery bypass grafting for atherosclerotic heart disease is commonly performed throughout the world. Complications of coronary artery bypass grafting include saphenous neuralgia due to injury to the saphenous nerve duringharvest of the saphenous vein. Dermatologic complications of coronaryrevascularization are infrequently reported and include an eruption overlying the vein donor-site scar. OBSERVATIONS--We describe two cases of saphenous vein donorsite dermatitis associated with sensory peripheral neuropathy in the distributionof the dermatitis. Histopathologic studies revealed a subacute spongiotic dermatitis. The course of the eruption was characterized by exacerbations and remissions with gradual resolution of both the dermatitis and neuropathy over a1- to 2-year period. CONCLUSIONS--Our cases are unique because the dermatitis developed in the area of the neurologic changes. We propose that the dermatitis may be a trophic change secondary to saphenous neuralgia.

Read More

Atypical plaque on the hand

Submitted by Dr Henry Foong, Ipoh, Malaysia

An 80-year-old retired goldsmith presented with 4-month history of an ulcerated plaque on the left hand. It had gradually increased in size. His past medical history included hypertension, diabetes mellitus, and ischemic heart disease. His medications included norvasc, zocor, ticlid and amaryl.

Examination of the skin showed a localized ulcerated verrucous plaque 6 x 6 cm on the dorsum of the left hand. Closer examination showed slough and blackish dots on the surface of the plaque. Regional nodes were not enlarged.

Our presumptive diagnosis is either atypical mycobacterium infection or chromoblastomycosis.

The epithelium shows pseudoepitheliomatous hyperplasia. The upper dermis is densely infiltrated by acute and chronic inflammatory cells. Neutrophils are also noted in the lining epithelium. No granulomas or Langhan's giant cells are seen. No microorganisms are noted. Negative for dysplasia and malignancy. Ziehl-Neelsen stain for acid fast bacilli is negative. Periodic acid Schiff stain for fungi is negative. Culture for AFB and fungal organism were negative

He was initially treated with itraconazole 100mg bd and after 2 weeks there was no improvement at all. Bactrim 2 tab daily was added and this time it showed improvement after 2 weeks of the combination.

One of the differential that was considered is pustular vasculitis or neutrophilic dermatosis of the dorsum of the hands. Points supporting this diagnosis include pseudoepitheliomatous hyperplasia and the absences of granuloma on histology examination.

I suspect this could be atypical mycobacterium infection based on the empirical therapeutic response to bactrim. I wonder what your views are with regard to this case?

Read More

Annals of Puzzling Purpuras

Percussion Purpura -- Taiko Purpura
Submitted by Trudi Shim, San Antonio, Texas

History: The patient is a 63 year-old Japanese-Hawaiian woman who plays Taiko drums as a hobby. She has a past history of porphyria cutanea tarda (PCT) from estrogens which is now quiescent. A few years back, she developed tendonitis of her wrists and received cortisone injections near each wrist from two different physicians. When she developed a hypopigmented patch of skin on her right forearm she attributed it to the cortisone injection. The patch was characterized by an large, flat, smooth area of hypopigmentation, and occasionally some round, bright red spots appeared in the hypopigmented area. They would disappear after a week or two. She consulted a dermatologist a year ago because she worried that this might be contagious. He diagnosed tinea, but did no KOH prep and she has been faithfully applying clotrimazole ever since, but without relief. The dermatologist also raised the spectre of Hansen's Disease which worried the patient, a retired public health nurse, greatly. She does not have any known skin problems elsewhere on her body at this time.

On Examination: The patch is now predominately reddish in color, with sharp irregular borders. The skin is fragile in the sense that if she hits her arm against something, it will break and take a while to heal. - similar to what used to happen way back when she had PCT. This only occurs in the localized area of hypopigmentation.

Clinical Photos:
Patient and Taiko




Discussion: This case presentation contains some interesting points. The patient is a late middle-aged Japanese-Hawaiian woman who has lived in the sub-tropics for her entire life. Thus, she has a fair amount of solar elastosis. The intra-articular corticosteroid most likely caused more localized atrophy and the trauma the arm experienced doing heavy drumming was all she needed to cause purpura. The diagnosis of tinea without a KOH prep showed a certain cavalier approach on the part of her practitioner; and the suggestion of the possibility of Hansen's Disease should not have been made unless a biopsy followed. Leprosy in economically comfortable people born in Hawaii is very unusual. Most cases seen in the Hawaiian Islands today are in immigrants from the Philippines, Oceania and Southeast Asia. Purpura is not a usual finding, but rather a hypopigmented anesthetic plaque (tuberculoid leprosy). Lepromatous leprosy would often appear more dramatically. The patient's PCT is likely not related, but she should have regular liver function studies and ferritin levels looked at. In the absence of other findings urinary porphyrins may not be necessary. "Percussion Purpura" while likely not super rare, has not been reported before.

Comments: Your thoughts and questions will be most welcome.

Read More

Parastomal Ulceration

Presented by Amanda Oakley, Hamilton, NZ

The patient is a 44 year old man with parastomal ulceration over the last 12 months.
He had a stable stoma for 12 years, following colostomy to remove rectal tumour (carcinoid) and is healthy otherwise with no bowel problems and no skin disease elsewhere.

Last year he received IV antibiotics for peristomal cellulitis, with complete recovery. A month or so later the peristomal skin began ulcerating. Partial healing is followed by skin lifting off at bag changes alternate days, leaving painful ulceration. Meticulous hygiene resulted in no improvement with different devices or topical steroid for one month, applied as beclomethasone nasal spray. Now trying clobetasol solution on appliance, allowed to dry before fitting to skin. He is on no medications.

Swab: group G streptococcus on two swabs - no deep fungi or mycobacteria.
Blood screen: all normal - no sign carcinoid or other disease

Clinical Photos (July '09 (top) and February '09 bottom):


Histology: paucicellular; subepidermal clefting. Not diagnostic.

Dr. Oakley's Comments: Most stomal rashes are dealt with by stoma nurses and a dermatologist's opinion is rarely sought; so we don't see many of them. I see irritant dermatitis from time to time and it responds to topical steroids. He has no risk factors for pyoderma gangrenosum, and the histology is not typical of that.

Questions: Could group G streptococcus do this? There is no cellulitis or abscess formation and I have prescribed antibiotics without improvement.
Any suggestions re: diagnosis and treatment will be gratefully received! I am hoping some dermatologists have greater exposure to stomal disease and I can benefit from their experience.

Reference:
Yeo H, Abir F, Longo WE. Management of parastomal ulcers.
World J Gastroenterol. 2006 28;12(20):3133-7.
Management of surgically placed ostomies is an important aspect of any general surgical or colon and rectal surgery practice. Complications with surgically placed ostomies are common and their causes are multifactorial. Parastomal ulceration, although rare, is a particularly difficult management problem. We conducted a literature search using MD Consult, Science Direct, OVID, Medline, and Cochrane Databases to review the causes and management options of parastomal ulceration. Both the etiology and treatments are varied. Different physicians and ostomy specialists have used a large array of methods to manage parastomal ulcers; these including local wound care; steroid creams; systemic steroids; and, when conservative measures fail, surgery. Most patients with parastomal ulcers who do not have associated IBD or peristomal pyoderma gangrenosum (PPG) often respond quickly to local wound care and conservative management. Patients with PPG, IBD, or other systemic causes of their ulceration need both systemic and local care and are more likely to need long term treatment and possibly surgical revision of the ostomy. The treatment is complicated, but improved with the help of ostomy specialists. Note: This reference is available as free full text from the publisher.

Read More

Localized Bullae

This healthy 83 year-old man has had a one year history of bullae and vesicles on the medial aspect of the left knee. They come and go. He is on no new medications and does not take any drugss on an as necessary or intermittent basis. His medications consist of valsartan (Diovan), simvastatin and omeprazole (Prilosec).

O/E: A collection of vesicles and bullae left knee.

Clinical Photo:


Lab and Path:
Bacterial Culture 8/14/o9 Negative
Biopsies were done by two other dermatologists (will try to get results). Apparently, no firm diagnosis was made.

Path Report: 9/30/08 Perivascular and interstitial dermatitis with mixed cell infiltrate including eosiniphils. Dermal hypersensitivity reaction. "These findings may be seen in the prebullous lesions of pemphigoid." DIF was negative.

Diagnosis:
Consider localized bullous pemphigoid.

Discussion: This is an 82 yo man with a one year history of a localized bullous disorder. The initial pathology showed an inflammatory process with eosinophils. The bullous process has stayed localized to the left knee. It seems likely that this is localized bullous pemphigoid. There is a "pretibial variant" and this may be related. Apparently, many of these patients have negative direct immunofluorescence (See ref. below)
Plan to treat initially with clobetasol ointment and if does well follow with tactolimus ointment 0.1%.

Questions: What do you think? What else is in your differential diagnosis? Therapeutic options?

Reference:

Kurzhals G, et. al. [Localized cicatricial bullous
pemphigoid of the Brunsting-Perry type] Hautartz.
1993 Feb;44(2):110-3 [Article in German]
Localized cicatricial pemphigoid of the Brunsting-
Perry type is a very rare bullous condition, which
has so far been reported in 51 cases. It is
characterized by scarring blisters confined to the
head, scalp and neck.  Diagnosis can be difficult
because of the discrete skin lesions, often repeatedly
false-negative direct immunofluorescence, and the
absence of circulating antibodies. We report on a
87-year-old male patient with the typical clinical
feature of a cicatricial pemphigoid of the Brunsting-
Perry type and give a reviewof the 51 cases published
in the world literature.

Follow-up Photo (08/21/09):  The patient was seen after a week for a second visit.  No
treatment had been rendered and the bullae had resolved.  One wonders
what triggers the bullae?  He's a tennis player, so could it be minor
trauma, UVL?

Read More

Tan Papules in a Child

Abstract: Eight year old boy with six month hx of tan macules

HPI: This otherwise healthy boy has had a six-month history of asymptomatic tan macules on his torso. Takes no meds by mouth and is asymptomatic.

O/E: Six - eight smooth surfaced tan macules measuring from 5 mm to 15 mm in diameter on torso. After lesions are rubbed they urticate mildly and are faint pink. Dermographia is negative.

Photos:




























Pathology:

Diagnosis:

Read More