Large, Itchy Bumps All Over the Body

Presenter: Nilam Amin DO, Marcy Alvarez DO, Raymond Ramirez DO

Dermatology Program: New York United Medical Center, New York

Program Director: Cindy Hoffman, D.O.

Submitted on: January 16, 2005

CHIEF COMPLAINT: Large, Itchy Bumps All Over the Body x 3 days

CLINICAL HISTORY: 60 years old Hispanic male presented with with diffusely spread large, pruritic and painful bumps for three days. Denies burning, discharge, fever or other constitutional symptoms. Has tried topical corticosteroids, blinded biologic trial drug for psoriasis (name unknown), phototherapy, and etanercept (Enbrel®). This patient was diagnosed with chronic plaque psoriasis in 1989. He had been treated with multiple different regimens without significant improvement. Three months prior to his presenting complaint, he has treated with etanercept 25 mg SQ injections BIW. He discontinued etanercept after two months of treatment secondary to the complaint of severe headache. The patient presented to our clinic five months after discontinuation of the injectable biologic. He denies other psoriasis treatments between the time of discontinuation and the outbreak of his eruption. He denies household contacts with similar complaints, recent travel, or prior episodes of similar lesions.

PHYSICAL EXAM:
Multiple, large (ranging from 1-25 cm), discrete, well-defined, hyperkeratotic, hyperpigmented nodules and plaques on the scalp, face, trunk, and extremities.

There was no pre- or post-auricular, cervical, supraclavicular, or axillary lymphadenopathy noted.

LABORATORY TESTS:

Basic Metabolic Panel: Within Normal Limits
CBC with differential: Within Normal Limits
ANA: negative ESR: 4 (mm/Hr) RPR: non-reactive
Hepatitis Panel: Anti-HCV: non-reactive Anti-HBcore: non-reactive
Anti-HBsAg: non-reactive HBsAb qual: non-reactive
HAV Ab total: Positive HAV Ab(IgM): Negative

Cellular Immune Panel: CD3%: 71 Abs CD3+: 1427
CD4%: 42 Abs CD4+: 844
CD8%: 30 Helper/Suppressor Ratio: 1.4

DERMATOHISTOPATHOLOGY:

Histopathologic findings include eruptive hyperplasia with marked epidermal pallor, parakeratosis, numerous intraepidermal neutrophils, and thinning of the suprapapillary epidermal plate. The dermis shows evidence of edema, upward enlargement of the dermal papilla, and digitated, tortuous dermal capillaries.