1) 27 yo woman with few year history of unilateral erythema of right cheek. No papules when initially seen. Erythema waxes and wanes -- has been worse by history.
Rx? I may start with doxycycline, cold compresses, ? ivermectin
2) 57 yo man with a long history of psoriasis. Was using clobetasol ointment and clobetasol scalp solution for a number of years. Last seen > 1 year ago. He was also on methotrexate 10 mg per week. Facial erythema and papules started in the past few months. He also noted easy bruising, and loss of muscle mass in brachial area. BP 160/100. Exam also shows mild truncal obesity and ecchymoses.
Plan: CBC, Chemistries, 8 am and 4 pm serum cortisol. Endocrine consult.
Macrocytosis, plt 77,000
Alk phos 425 (18 - 210), SGOT 182 (15 - 37)
Serum Cortisol a.m. 24, p.m. 11 AM ( 4-22), (PM 3 - 17)
What are your thoughts?
I find both cases very interesting especially the first patient with the unilateral erythema and pustular eruptions. I would consider trying twice a week elimite cream or the new medicine, soolantra.
ReplyDeletesoolantra is expensive, there are coupons available to be used to do a trial of the medication. I have seen dramatic responses in 5 patients.
The second patient is also very interesting. I had a similar patient who was wheel chair bound and had a buffalo hump that was attributed to her posture, inability to walk due to her severe rheumatoid arthritis. She also had easy bruisability. A very astute internist, not me, worked her up for her cushingoid findings and found a pituitary adenoma in a 62 year old woman. She has been dramatically better with treatment.