Case25

A Puzzling Facial Rash on a 17-Year-Old Boy

Background

A 17-year-old male high school student presents to the pediatric infectious disease clinic complaining of a 10-day history of a facial rash that "won't get better." The patient had previously visited his primary care provider (PCP), who started the patient on amoxicillin-clavulanic acid 8 days ago. The rash did not improve on the antibiotic, and as a result, it was discontinued and the patient switched to trimethoprim-sulfamethoxazole. No improvement was noted with the second round of antibiotic therapy; the rash continued to spread, and the lesions increased in number. The patient was subsequently advised to follow up with the infectious disease clinic.
At the infectious disease clinic, the patient states that the rash started with several pimples over the forehead and cheek and then continued to spread and involve most of the right side of his face. The lesions are not itchy, but they are painful. The patient has no known drug allergies. His immunizations are up to date. He is very active on the wrestling team and was happily preparing for an upcoming competition. The patient denies having any weight loss, headaches, dizziness, photophobia, fever, or chills. The family history is non-contributory.



On physical examination, the patient is alert and orientated. His oral temperature is 97.0°F (36.1°C). The patient has normal heart sounds, his pulse has a regular rhythm of 97 bpm, and his blood pressure is 125/75 mm Hg. His lungs are clear, and his respiratory rate is 12 breaths/min. The examination of the head, eyes, ears, and nose is remarkable for multiple vesicular lesions measuring about 0.5 cm in diameter .There is bilateral submandibular lymph gland enlargement measuring 1.5 cm by 1 cm. The neck is supple. His abdomen is soft and nontender to deep palpation in the epigastric region, and no organomegaly is noted. A complete blood count (CBC) taken at the PCP's office showed a white blood cell (WBC) count of 7.4 × 103/µL (7.4 × 109/L), with a normal differential; a hemoglobin of 13.6 g/dl (136 g/L); a hematocrit of 38.3% (0.3830); and a platelet count of 298 × 103/µL (298 × 109/L).

What is most likely diagnose?







Correct answer is "d" Herpes gladiatorum.

Case24

Back ground

A 34-year-old white woman was seen in consultation regarding a 1-month history of erythematous papules and bullae on the palms and soles. Associated intense pruritus was noted. Initial treatment with an over-the-counter antifungal cream was unsuccessful. The eruption worsened despite treatment with a first-generation cephalosporin and acyclovir, as provided by her primary care physician. There were no reported exposures to toxins, irritants, or potential allergens. The patient was on no other medications, vitamins, or supplements.


On examination, the patient demonstrated tense vesicular lesions on the lateral aspects of the digits of the hands and feet and also on the palmoplantar surfaces (Figure 1). These vesicles terminated abruptly at the wrists and ankles (Figure 2). There was little involvement of the dorsal surfaces. No targetoid lesions were noted. The conjunctiva and oral and genital mucosa were within normal limits. No other cutaneous abnormalities were noted on examination.

What is most likely diagnose?





Answer is "b" Dyshidrotic dermatitis/pompholyx.

Case23

Background

A 72-year-old handicrafts teacher. Recently widowed, Mother of 2 children and grandmother of 4.
She has been diagnosed with a number of chronic health problems over the last several years and is currently receiving treatment for hypertension, osteoarthritis, and chronic obstructive pulmonary disease (COPD).
Despite her doctor's advice, she has found it difficult to lose weight and quit smoking.
Today, her medical status is:
Height: 5'5"; weight:184 lbs; BMI: 30.6 kg/m2
BP: 141/89 mm Hg
Lungs: clear to percussion, but mild wheezing bilaterally
For hypertension: lisinopril 10 mg/hydrochlorothiazide 12.5 mg daily.
For osteoarthritis of the knee: naproxen sodium 375 mg twice daily.
For COPD: fluticasone propionate 100 mcg/albuterol 50 mcg inhalation powder once daily.
Presenting symptoms:
Severe, persistent throbbing pain in the right chest wall, extending from the back to the nipple line.
Pain began with an attack of herpes zoster (HZ) 2 years ago; pain continued through course of acyclovir therapy and persisted after healing of the rash.
Examination reveals an area that is extremely sensitive to light touch within and outside the affected dermatome.
There is some scarring at the site.
she describes her pain as continuous–"like a deep burn" with episodes of sensations that feel like an electric shock

• Which of the following are the most reliable types of information to
  diagnose the cause of her pain?

The correct answer is 'd' comprehensive and focused patient history and imaging studies.