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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Case from Cambodia

These photos were sent to Dr. Doug Johnson from Cambodia without any information.
It's sad to think that adequate medical care could have likely prevented most of this.
Your comments are welcome.

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The Case of the Maltese Cur

A 69-year-old woman presented with a six-month history of a lesion on the bulb of the nose. This began after her Maltese dog scratched her on the nose and the area has never healed. She used mupirocin ointment without relief, in addition.

EXAMINATION: The examination shows a light-complected Caucasian. She has an irregular 1 cm in diameter crusted area on the bulb of the nose.

Pathology: A shave biopsy was taken for diagnostic purposes. This showed an infiltrating BCC. The photomicrographs were taken by Dr. Jag Bhawan, SkinPath at Boston University School of medicine.




4x













10x








20x








Plan: I will recommend micrographic surgery.

Question: I hear this story frequently. My cat, dog, grandkid scratched me on my nose, cheek, etc. and it didn't heal properly. I assume it's just chance -- but what do you think. Should she put the dog down? What would PETA say?

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Fascinoma

Every day one sees something one never encountered before.
Here's a diagnostic and perhaps therapeutic challenge.

This well-nourished, alert, well-oriented 82 yo woman presents with a six month history of an erosive dermatitis of the perirectal and vaginal area. Over the past year she has had pathological fractures of both femurs and a history of herpes zoster (not cofirmed). Remarkably, she has put up with these erosions which are apparently not that painful.

O/E: Sharply marginated clean erosions around rectum and vagina. Similar lesions are found in skin folds (abdominal and under breasts). She has some oral ulcerations under her dentures and crusted lesions on the scalp. No vesicles or bullae seen or noted by other physicians.

Lab: At this time CBC normal. Antibodies for pemphigus and pemphigoid are negative.

Biopsies performed on Feb. 8, 2007 for H&E and DIF.

Who has seen a similar picture?

I am thinking about:
Pemphigus variant
Necrolytic migratory erythema
Acrodermatitis enteropathica

Will order zinc and glucagon levels if pathology is not helpful. Someone may have seen this picture before.

Updated February 16, 2007
Here's a follow-up on this patient...
Path: Shows:
Subepidermal blister with dense superficial and mid perivascular and interstitial mixed inflammatory cell infiltrate including lymphocytes, plasma cells, eosinophils , dermal edema, and papillary dermal fibrosis .
NOTE : These changes are non-diagnostic but suggestive of cicatricial pemphigoid in view of the immunofluorescence findings (see below).

See immunofluorescence results and note. (Photo by Jag Bhawan)
DIRECT IMMUNOFLUORESCENCE RESULTS : Linear "Immunostaining" was observed with IgG, IgA and intermittent with C3 at dermal epidermal junction and with C3 and IgA around blood vessels and appendages.
NOTE : These changes are non-diagnostic but consistent with cicatricial pemphigoid.

Putting this together, I suspect this is indeed an unusual variant of cicatricial pemphigoid. I have started her on prednisone 20 mg tid and tacrolimus ointment 0.1% (but insurance plans here do not always cover the ointment). A G6PD was ordered since I will probably use Dapson as well. I expect the management will be difficult.

February 22
Patient seen in f/u. To my surprise, there is early reepithelialization of perineal erosions. Oral erosions still prominent. I've lowered her prednisone to 20 mg bid -- awaiting G6PD results. Perhaps, the tacrolimus is helping. The comments havc been helpful.

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