Wednesday, April 16, 2008

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.

8 comments:

  1. Thanks for sharing this case, another dermatologic riddle!!!. It is not clear if scalp lesion also started following EEG lead application, we have seen 2 children in our centre who developed necrotic ischar like lesions at the site of application of ECG (not EEG) leads while they were admitted in Pediatric ICU. Aspergillus was isolated from one of the ulcer while in other contact dermatitis and secondary bacterial infection were considered. In this case single lesion over scalp has persisted for more than 6 months, i don't think EPD of scalp as a possibility, Non healing (progressing) nature of ulcerated plaque should make us think of infection (atypical mycobacterial/aspergillus), lymphoma or pyoderma gangrenosum. However it is very well defined annular as if 'branded' in appearance favouring factitious dermatosis.
    Lesions over upper back and shoulder are bizarre and streaky resembling to that of factitial dermatitis.

    Regarding further management - shall try to rule out serious possibilities as listed above by biopsy and repeat culture and then has to consider psychiatrist help.
    Till that time symptomatic management with oral/ topical antibiotics and care of his other medical co-morbidities.

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  2. My first impression is pyoderma gangrenosum and associated pathergy. The clinical ddx would include ecthyma, leishmaniasis, atypical mycobaceriosis, factitious dermatitis, and even SCC. The management should be guided by repeat cultures and histopathology.

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  3. I would re-culture and check for MRSA. Unfortunately, many of the lesions on the arms look like they are self-induced. If possible, I would find a way to cover and leave area covered for 4-5 days and to use something like unna boot...or duoderm...but with coverage of antibiotics like levaquin orally.

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  4. Steve StoneApril 21, 2008

    Sounds like pathergy, but looks factitial. I'd go with occlusive therapy.

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  5. Amit PandyaApril 21, 2008

    I agree with culturing and treating with antibiotics, perhaps long term, along with covering the area. Maybe an ID consult and IV antibiotics would help after culture and sensitivity results are obtained.

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  6. factitious dermatitis, is my professinol diagnosis, so patient need a psychatric consultant, in addition to wound care and cover antibiotics,

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  7. This is pyoderma gangrenosum.It is very unusaul see dermatitis artefacta in areas. out of the reach of the hands like back and shoulder.Underlying malignacy should be looked for.
    khalifa sharquie

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  8. Any updates? Was occlusion tried at all?

    ReplyDelete

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