2015-2016 Academic Year Archives - Dermatology Grand Rounds

54 year old man with multiple sores

Chief Editor — Fri, 27 May 2016 06:10:47 +0000

Presenter: Mike Garone DO, Natalie Steinhoff DO, Jessie Perkins DO

Dermatology Program: NSUCOM/Largo Medical Center

CHIEF COMPLAINT: Multiple "sores" on the left hand, chest, and right neck

CLINICAL HISTORY: A 54-year-old man presents with multiple "sores" on his left hand, chest, and right neck. His clinical history reveals no signs of fevers, chills, night sweats, or unexplained weight loss. He denies experiencing nasal congestion, sore throat, epistaxis, mucosal erosions, nausea, vomiting, diarrhea, hematochezia, or melena. There is no reported history of immunodeficiency or HIV. However, he does report chest congestion and rhinorrhea occurring every morning, although he denies any prior history of allergic rhinitis. The patient's past medical history includes hypothyroidism, and he has a negative surgical history. His family history is notable for a father with prostate cancer. Socially, he works as a government-contracted pilot, making frequent trips to the Middle East. He consumes alcohol socially but denies tobacco use or illicit drug use. His current medication includes Levothyroxine, and he has no known drug allergies. Three months prior to this presentation, the patient was in Iraq, where he experienced insect bites. He reports that some of these bug bites never healed. Initially, he was treated by his primary care physician with permethrin and triamcinolone 0.1% topical cream. Subsequently, he was treated with systemic azithromycin and pimecrolimus topical.

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Painful rash in 15 year-old female

Chief Editor — Fri, 27 May 2016 06:03:58 +0000

Presenter: Leslie Mills, DO

Dermatology Program: West Palm Hospital/PBCGME

CHIEF COMPLAINT: Painful rash involving her face, neck, and ears

CLINICAL HISTORY: A 15-year-old female presented to the Emergency Department with a painful rash affecting her face, neck, and ears. Four days prior to admission, after returning from Georgia, she experienced tenderness and pressure in her facial area, which progressed to significant edema, particularly in the periorbital region. The rash initially appeared as intensely pruritic, erythematous papules and vesicles that rapidly ulcerated, producing clear-yellow drainage. The patient reported associated ocular pain but denied experiencing oral lesions, fever, or chills. She also had no recent trauma, sick contacts, or exposure to animals, nor had she engaged in outdoor activities or used new products.

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Pruritic rash with proximal muscle weakness

Chief Editor — Wed, 27 Apr 2016 05:59:33 +0000

Presenter: Duggan C., Jajou P.

Dermatology Program: Beaumont Hospital Trenton

CHIEF COMPLAINT: Pruritic spreading rash

CLINICAL HISTORY: The patient is a 64-year-old female with hypertension, hyperlipidemia, hypercholesterolemia, hypothyroid, and depression who presented to the clinic with a pruritic rash that started on her left wrist and then spread to her right arm, chest, scalp, and posterior neck. She denied any recent sun exposure. The patient admits to some difficulty arising from a seated position as well as fatigue while combing her hair. The patient had been given multiple topical steroids with only minimal relief of the rash and the associated pruritus. Lab work, muscle, and skin biopsy were ordered, as well as follow up with rheumatology in regards to a muscle biopsy. The patient had been to multiple physicians prior to coming to our clinic including an internal medicine physician, dermatologist, allergist, rheumatologist, as well as her primary care physician. The patient admits having all normal screening exams such as a mammogram/colonoscopy/pelvic examination as well as a recent CT of her chest, abdomen, and pelvis which didn’t reveal any abnormalities.

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Burning and stinging red nodules on the dorsum of hands

Chief Editor — Wed, 27 Apr 2016 05:53:11 +0000

Presenter: Jessica Vincent, DO

Dermatology Program: OhioHealth O'bleness Hospital

CHIEF COMPLAINT: Burning and stinging red nodules on the dorsum of his hands x 1 year

CLINICAL HISTORY: A 57-year-old male presented to the current authors complaining of burning and stinging red nodules on the dorsum of his hands for about 1 year. He also admitted to the persistence of an episodic rash over the lower legs and bilateral flanks he had originally presented with 7 years prior. He was briefly treated with an oral prednisone taper and topical corticosteroids including triamcinolone 0.1% cream and clobetasol 0.05% cream without improvement. A biopsy 7 years prior revealed leukocytoclastic vasculitis (LCV) with prominent eosinophils. At the time, it was felt his skin findings were a manifestation of drug hypersensitivity, likely to opioid use. The patient was subsequently lost to follow up.

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A 40 year old female with left sided facial swelling and lip swelling

Chief Editor — Sat, 27 Feb 2016 05:49:41 +0000

Presenter: Huyenlan Nguyen, DO, Elise Grgurich, DO

Dermatology Program: Lehigh Valley Health Network/PCOM

CHIEF COMPLAINT: Left-sided facial swelling and lip swelling

CLINICAL HISTORY: A 40-year-old female with left-sided facial swelling and lip swelling. The most recent episode occurred one month ago and was associated with swelling of the face and lips. She feels the self-limited flares are related to stress and denies any associated new medications or provoking foods. She occasionally has numbness on the left side of her face that she attributes to her history of Bell’s palsy. She was treated with a course of prednisone and responded well.

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Seven year old male with full body eruption

Chief Editor — Sun, 27 Dec 2015 05:44:51 +0000

Presenter: Trent Gay, DO

Dermatology Program: Lewis Gale Hospital Montgomery

CHIEF COMPLAINT: Full body eruption

CLINICAL HISTORY: A 70-year-old male presented with a 4-month history of an asymptomatic, scaly, persistent full-body rash. He reported no preceding infections or recent travel and is otherwise in good health. His past medical history was unremarkable, with no current medications, significant family history, or surgical history. The patient lives at home with his parents, denies alcohol or tobacco use, and attends elementary school. He has no known drug allergies. At the time of presentation, two punch biopsies were performed, and the patient was prescribed desonide ointment and Sarna lotion. The biopsy results revealed non-specific spongiotic dermatitis. One month later, the patient returned for a follow-up and was placed on an oral steroid taper. Although the rash resolved during the steroid treatment, it reappeared upon tapering and remained unresponsive to the previous topical medications. Consequently, two additional punch biopsies were performed. Following the results, the patient was started on oral erythromycin.

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Long standing upper body rash

Chief Editor — Fri, 27 Nov 2015 05:41:42 +0000

Presenter: Stephen Colden Cahill, DO, Stephanie Juliet Kang, DO

Dermatology Program: Tri-county Dermatology, Ohio

CHIEF COMPLAINT: Rash on the body

CLINICAL HISTORY: In August, a 37-year-old Caucasian female (Fitzpatrick skin type 2) with a past medical history of depression, DJD, and spinal stenosis, presented for consultation regarding a five year pruritic rash over her face, neck, chest, shoulders, and arms. She was seen one month ago by her primary care physician, who performed lab work which showed an elevated CRP 31.3 (normal 0-5mG/L), normal CBC w/diff and negative ANA. She was placed on a 7 day prednisone taper and OTC loratidine. Her symptoms had mild short term relief and then promptly returned. She reports suffering from similar lesions over the last five years which have waxed and waned in intensity. She denies any new recent medications or herbal supplement additions. She cannot specifically associate the lesions with sun exposure. She denies any systemic symptoms, other than low back pain which has been an ongoing issue for several years. She is an active one pack per day smoker and occasional social drinker, denies any illicit or recreational drug use.

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Infection of the lower leg not responding to antimicrobial therapy

Chief Editor — Tue, 27 Oct 2015 05:38:32 +0000

Presenter: Shannon McKeen, DO

Dermatology Program: MSUCOM/Lakeland Regional Medical Center

CHIEF COMPLAINT: Infection on the left ankle

CLINICAL HISTORY: A 9-year-old female presented for evaluation of an infection on the left ankle. The patient injured her leg on a rock in Mobile Bay several months ago while on vacation with her family in Alabama. The wound was cultured and the patient was empirically started on Cephalexin by her primary care physician with little improvement. Wound culture from the outside office showed rare Staphylococcus epidermidis susceptible to Trimethoprim-Sulfamethoxazole. The patient is up to date on her Tetanus and other immunizations. No recent travel out of the country. The patient was started on Trimethoprim-Sulfamethoxazole and referred to Dermatology.

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Generalized rash in 33 year-old female

Chief Editor — Tue, 27 Oct 2015 05:35:56 +0000

Presenter: Liza Brown, DO, Francisco Kerdel, MD

Dermatology Program: Larkin Community Hospital (LCH/NSU-COM)

CHIEF COMPLAINT: Generalized “rash"

CLINICAL HISTORY: The patient is a 33-year-old female with a past medical history significant for asthma and bipolar disorder, who presented to Larkin Hospital dermatology service as a direct transfer for a “generalized rash”. Upon questioning, the patient stated she was started on Lamictal July 13, 2015, for her bipolar disorder. Two weeks after starting Lamictal patient reported developing angioedema and went to an ER near her home. She was given epinephrine and IV steroids with mild relief and was discharged home at that time. August 2, 2015 patient went back to the ER after the development of new symptoms; a generalized targetoid rash that began cephalad and extended caudally. The patient was admitted for three days and then was transferred to Larkin Community Hospital on August 5, 2015, after she began having sloughing of skin and dysphagia. Complete review of systems was within normal limits other than mentioned previously. The patient denied previous drug allergies, other new medications, or recent travel.

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Atrophic dermatosis on bilateral legs

Chief Editor — Thu, 27 Aug 2015 05:33:27 +0000

Presenter: Jennifer Peterson DO, Angelo Petropolis MD, Amy Weierman PA-C

Dermatology Program: Advanced Desert Dermatology

CHIEF COMPLAINT: Odd blotchiness on legs

CLINICAL HISTORY: A 65-year-old Caucasian female presented for evaluation of odd blotchiness on her legs. The patient reported onset of blotchiness on her legs approximately 1 month prior to presentation. She denied any local or constitutional symptoms associated with skin lesions. No history of recent travel or medication changes. Her past medical history is significant for hypothyroidism (controlled on levothyroxine), chronic arthritis, morbid obesity status-post gastric bypass surgery (with subsequent profound weight loss), and anemia secondary to malabsorption. A 10-point review of systems was performed, and did not reveal any new, evolving, or unexplained signs or symptoms.

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