Friday, February 08, 2008

Umbilical Erosions

[ See end for final diagnosis]
Abstract:
71 yo woman with three week history of genital, anal and umbilical erosions.
HPI: This healthy 71 yo woman had vaginal prutitus for a few weeks. She saw her gynecologist who prescribed an estrogen cream. It got worse. She was then given clobetasol oint. It did not improve. She tried acyclovir ointment -- not much change. I saw her at this point. I recommended continuing clobetasol ointment, but after a few days getting worse. No new meds. Takes occasional acetoaminophen and diphenylhydramine.
O/E: Periumbilical erosive dermatitis. No frank vesicles. There was only faint erythema of the vulva and anal areas and very slight erosion left groin.



Lab: CBC normal, Chemistries normal. KOH from umbilicus negative. Bacterial culture taken.
Pathology: Biopsies for H&E and perilesional for DIF done Feb. 8, 2008
Diagnosis: I am considering the following:
A vesiculobullous disorder
Fixed drug eruption (but have no likely candidates)
Contact dermatitis unlikely.
HSV a long shot.
Periumbilical cellulitis? B-Strep perianal cellulitis can look similar
What have I missed?
Questions: What are your thoughts? Biopsy and culture should be ready in three days.

The bacterial skin culture grew out Group A Beta Strep. The pathology was consistent with cellulitis. No evidence of an acantholytic process. It is likely that this began with a perianal/vaginal streptococcal cellulitis and spread to the umbilicus. Periumbilical streptococcal cellulitis has not been reported in adults. The patient was started on Pen VK 250 mg qid and mupirocin ointment. Fout days later she was almost completely clear. Unfortunately, the fluorescent correction was not on when picture was taken.

12 comments:

  1. First of all i will exclude MF,Extramammary Paget's Disease and some others paraneoplastic disease in this age and situation.

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  2. I will sonsider extramammary paget's Disease, however odd feature is multiple lesions. In case of a young female with umbilical lesion only extrmapelvic endometriosis could be a differential diagnosis.
    Abscence of history of bullae formation make pemphigoid a less likely possibility. Histopathology should solve the issue.

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  3. I would also consider necrolytic migratory erythema and its associations such as glucagonoma. any stomatitis with this?

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  4. robert rudolphFebruary 09, 2008

    1. P.V. (especially a paraneoplastic variety)
    2. P.G.
    3. E.M.
    4. Drug

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  5. My first thought was could this be a Sister Mary Joseph nodule or other cutaneous metastasis. I agree with extramammary Paget's, BP, pemphigus, MF, fixed drug being possibilites. Anxious to hear the pathology!
    Matthew H Mahoney, MD

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  6. My ddx would be
    Intertrigo,
    Hailey Hailey disease,
    and extra mammary Paget's disease.

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  7. Necrolytic migratory erythema/Zinc deficiency came to mind as well.

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  8. Doug JohnsonFebruary 12, 2008

    I thought of doing a KOH and considering a DX of Psoriasis.

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  9. This may be 1) para neoplastic lesion ( glucagonoma, Sister Mary Joseph's nodule,extramammary Pget's disease) 2) Migratory Necrolytic Erythema.
    Do cancer and endocrine screening.

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  10. Khalifa SharquieFebruary 15, 2008

    Yes,this is a strange case. Intertrigo is the clinical diagnosis but what is the underlying cause?? Is it candidal? pemphigus vegetans of Hallopeou?? extracolonic Crohns ds? Biopsy will solve this problem.

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  11. This is a fascinating case. It reminds me of periorificial cellulitis. Yeah, this case should be written and documented.

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  12. does anyone know what Migratory Unticarea is ? what causes it and how is it treated?
    I would appreciate any medical help on this.
    Thank You

    J.C. Zacher

    email me: joannezacher@hotmail.com

    ReplyDelete

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