Know When to Cut, Know when to Punt

The patient is an 87 yo man with a mild dementia. He lives in an assisted care facility. Has an attentive and caring daughter. In October of 2007 he had a wide-local excision of s large SCC on the left forehead by a general surgeon. Path report showed "clear margins." When seen on May 30, 2008 a 4 x 3 cm recurrence was noted. The picture of the right TMJ area shows a scar from micrographic surgery from a similar lesion the patient had ~ 10 years ago. His daughter said it took 6 months to heal.





Questions:
1. What contributes to the aggressive behavior of this small subset of SCCs?
2. Would you refer to Mohs, XRT, or just watch?
3. Are you comfortable playing God with patients like these?

Comment: There is a subset of SCCs that metastasize and kill patients. MA Weinstock and his collaborators have written on this subject.

Weinstock MA, et. al.
Nonmelanoma skin cancer mortality. A population-based study.
Arch Dermatol. 1991 Aug;127(8):1194-7.

Department of Medicine, Veterans Affairs Medical Center
Providence, RI 02908.

To estimate the magnitude of nonmelanoma skin cancer mortality
and describe itsparameters, we reviewed the medical records of
all deaths certified as due to this cause among Rhode Island
residents from 1979 through 1987. After excluding acquired
immunodeficiency syndrome-associated Kaposi's sarcoma, we
confirmed that nonmelanoma skin cancer was the cause of death
for 51 individuals, a quarter of the number of melanoma deaths
reported. The age-adjusted nonmelanoma skin cancer mortality rate
was 0.44/10(5) per year. Fifty-nine percent were due to squamous
cell carcinoma, and 20% were due to basal cell carcinoma. Most
appeared actinically induced. Among deaths from SCCs, the mean age
was 73 years. At least 80% of the squamous cell carcinomas metas-
tasized, and 47% arose on the ear. None appeared due to refusal of
treatment. Among deaths frombasal cell carcinoma, the mean age was
85 years, and refusal of surgical  intervention was documented in
40%. Study of nonmelanoma skin cancer mortality provides for estimation
of the magnitude of this problem, complements otherstudies of
prognosis, and helps guide prevention, early detection, and treatment.

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Two Foot and One Hand Disease

These are the hands of a 35 year-old plumber I saw recently. He was not aware of a dermatitis of his feet, but inspection showed mild moccasin-type T. pedis on both feet and subtle onychomycosis. KOH prep from the right hand was positive for septate hyaline hyphae. We all see two foot and one hand disease regularly. Do you have any theories as to why only one hand is involved? This is a peculiar dermatologic vignette.



Right Hand


Left Hand

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Penile Pain

The patient is 40 yo heterosexual male in a monogamous relationship for the last 6 years. Neither he nor his partner has a history of having had sex with anyone else ever before.

Three months ago he had the onset of pain at the tip of his glans during coitus and experienced pain also on pulling at the tip of his foreskin. A month later he noticed a few grouped "vesicles" at the ventral tip of his glans. These lesions have persisted unchanged. The pain in these lesions persists since being first noticed.
Clinical Photo:


The wife is asymptomatic although she had symptoms suggestive of vaginitis 3-4 months back which improved on clotrimazole pessaries (this was almost the same time when the patient developed pain during coitus which has never subsided).

What is the diagnosis?
What would you do at this point?

Note: Two respondents have suggested "Pearly Penile Papules." This does not look like a typical case of PPP. For comparison a picture is below. PPP is usually around the corona and is rarely this symptomatic.

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21 yo man with warty plaque on foot

Presented by Henry Foong, Ipoh, Malaysia

A 21 yr old student presented with 5-year history of warty growth on the
right foot. It started as a small lesion which gradually got bigger.

Pertinent findings on examination were raised hyperkeratotic plaque 5 x 3 cm
on the medial border of the dorsum of the right foot. It has a verrucous
surface with blackish dots. Regional nodes were not palpable.




Clinically he has chromoblastomycosis of the right foot.

A biopsy was done and the epithelium shows marked acanthosis with elongation
of rete ridges and intraepithelial collections of neutrophils. The dermis is
densely infiltrated by lymphocytes, plasma cells and few neutrophils.
Culture of organism was not done.

I may repeat the biopsy and perform fungal culture.

I plan to treat him with liquid nitrogen together with some combination
therapy with antifungals: itraconazole 100mg bd ( 200mg bd??) for several
months together with another antifungals. 5FU or IV amphotericin.

Would appreciate your comments on this patient.

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No Man is an Island

Thallium poisoning with skin manifestations

Presented by Professor Khalifa Sharquie
Baghdad, Iraq

History: A few weeks ago, an outbreak of thallium poisoning occurred in Baghdad and all of the patients had positive tests for thallium. We had the opportunity to see cases with skin manifestations. All patients gave a history of eating cakes and presented to hospital with nausea, vomiting followed by mental and peripheral neurological complaints. The case I am presenting was that of a 30 yo adult male referred to me two weeks after poisoning. He had severe hair loss, both diffuse and patchy, affecting mainly scalp and body hair. Also he had a non-pruritic rash affecting the face, limbs and groins.

O/E: The striking findings were severe anagen hair loss, diffuse and in patches. The hairs were easily plucked and microscopically were typical anagen phase. The next important finding was dermatitis-like picture that covered the face especially around the mouth and the limbs mainly on the dorsae of both hands. The groins had intertrigo simulating tinea cruris. The rash was dusky red and ecchymotic in appearance.

Photographs:





This picture was strange enough to make one think about the following Differential Diagnosis:
Acquired zinc deficiency
Pellagra
Erythema multiforme
But only suspicion can lead you into right diagnosis. Accordingly, before the definite diagnosis was established, we gave oral zinc sulfate 100mg 3 times a day for some patients. Surprisingly they recovered and resolved.

Reason Presented: Thallium is nice rat poison since it is colorless, tasteless and odourless. It can be used as massive lethal chemical weapon and is practiced this way in Iraq as a way to kill people. It is my opinion that thallium should be prohibited and considered as a chemical weapon like nitrogen mustard. It is better to let rats run free than to kill human beings.

Reference: A good article on this subject appeared in the Archives of Dermatology in January, 2007. Short-term thallium intoxication: dermatological findings correlated with thallium concentration.
Arch Dermatol. 2007 Jan;143(1):93-8.
Lu CI, Huang CC, Chang YC, Tsai YT, Kuo HC, Chuang YH, Shih TS.
Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan.
One can view this free online: Arch Dermatol article

Comment: John Donne wrote: "All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Our Western civilization began in the Fertile Crescent. Iraq was at the epicenter. The strory told here diminishes all of us. Professor Sharquie bravely bears witness as he helps and serves his people.

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Stumped...

Abstract: 60 yo man with unusual cutaneous ulcers and erosions
Presented by Dr. Hamish Dunwoodie, Moncton, New Brunswick
HPI: The patient is a disabled physician's assistant who injured his scalp on a low basement ceiling beam around a year ago. When he was first seen he had a thick escar over the area. This was debrided and cultured. It grew Staph aureus with the usual sensitivities and he was treated with wet compresses, dicloxacillin and bactroban ointment. Since his initial visit 4 months back it has not gotten smaller and now the central portion reaches the calvarium. Over the past six weeks, he has developed similar lesions on shoulders and upper back. By history these began at sites of ECG leads.

Pertinent medical history is positive for insulin-dependent diabetes, hypertension and coronary artery disease. His medications include insulin, warfarin, enalapril, furosemide, ASA, oxycodone.

O/E: 3 cm ulcer mid parietal area of scalp. Erosions on both shoulders, surface somewhat escharotic. Some with irregular borders.

Photos:


4 months later








Lab: Occasional skin cultures positive for S. aureus (not MRSA), CBC shows mild normochromic normocytic anemia. (Hct 32.6.Hgb 11.2).

Pathology: "Ulceration with scar. No evidence of malignancy." Repeat biopsy April 18, 2008 from new lesion on shoulder send to Canadian National Pathology Lab.

Diagnosis: Non-healing erosions etiology unclear. One always considers factitial disease in health care professionals with atypical skin lesions and this man also has free access to needles as a diabetic. In a year, the scalp lesion has shown no tendency to improve.

Further Treatment: He was treated with topical corticosteroids in case this was erosive pustular dermatitis of the scalp (no response) and imiquimod in case erosion might have been hypergranulation tissue. (no response) We ordered Duoderm dressings, but they were too expensive for the patient.

Questions: Where would you go from here? Diagnostic and therapeutic suggestions.

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A Leg to Stand On

Abstract: 85 yo man with cellulitis and lymphedema s/p bypass surgery

HPI: In 2000, this retired professor had CABG surgery with saphenous vein harvesting of the left leg, In 2002, while visiting Vienna, he was hospitalized for cellulitis of the left leg and treated with i.v. antibiotics. In the subsequent years, he has had progressive lymphedema of the left leg with the development of elephiantiasis nostra verrucosa. In the past 6 months he has had four documented episodes of cellulitis which have necessitated antibiotics. Recently, he has developed a generalized dermatitis. His medications include: atenolol, amiodarone, digoxin, diovan, thyrpid, Coumadin, Lovastatin, ASA. He has a possible allergy to penicillin (has not taken it in 40 years). He is otherwise quite healthy and intellectually alert.

O/E: Chronic lymphedema left leg with erythema, scale and some honey-colored crust. The leg in involved from just below the knee to the foot. The left leg is only minimally warmer than the right leg. In addition, he has a wide-spread dermatitis consisting of erythematous scaly patches on legs, arms and abdomen -- sparing the face.

Photos:






Lab: His internist did a skin culture and CBC b efore sending him here (results not back) . He was on Bactrim at the time of the culture.

Diagnosis: Recurrent Cellulitis s/p saphenous veif harvesting wit the development of chronic lymphedema and early elephiantiasis nostras. This was reported in 1982 (see Reference). The wide-spread dermatitis may be an "id" reaction.

Questions:
1) What has been learned about this entity since 1982?
2) Should he be rechallenged with penicillin and kept on long-term antibiotic prophylaxis.
3) What role does "hypersensitivity" to bacterial exotoxins play in the dermatitis.
4) Does anyone have magic for cases such as this?
5) Allergic contact dermatitis will be ruled out by patch testing.

Comment: My plan at the moment is to "clean up" any residual infection, consider prophylactic antibiotics and work on the dermatitis. I will refer him to a lymphedema center, if possible, for evaluation. Aggressive management of his leg swelling will help. He was told not to bathe the leg and I think this sets him up for infection. Your thoughts will be greatly appreciated. This man's life revolves around his leg. He is a keen student, a political scientist and in his later years he must focus exclusively on a leg. Let's give him "a leg to stand on!"

Follow-up: The patient was treated with compression stockings, cephalexin 250 mg qid for two weeks (based on sensitivities), desoximetasone 0.25% cream and lymphatic massage. There was no evidence of tinea pedis. He has improved markedly.
Photos taken June 10, 2008





Reference:

Recurrent cellulitis after saphenous venectomy for coronary bypass surgery.
Baddour LM, Bisno AL.
Ann Intern Med. 1982 Oct;97(4):493-6.

We describe a previously unreported complication of coronary artery bypass
grafting, recurrent cellulitis. Five patients had 20 episodes of acute
cellulitis, each occurring in the lower extremity in which saphenous venectomy
had been done. The cases were striking because the patients presented with high
fever and considerable systemic toxicity. The appearance of the lesions, presence
in one case of obvious associated lymphangitis, and prompt response in three
instances to therapy with penicillin alone all suggest group A streptococcal
infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus
strain was isolated from the lesion. The pathogenesis of this syndrome remains
obscure but, based on our understanding of postsurgical erysipelas, this
cellulitis likely results from the interplay of several factors, including local
compromise of lymphatic drainage, direct bacterial invasion, and acquired
hypersensitivity to streptococcal exotoxins.

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