Tuesday, September 05, 2017

Man from India with Wide-Spread Vesicular Eruption

Presented by Dr. Bassem Ghali
Jagadguru Sri Shivarathreeswara University
Mysuru, India

The patient is a 60 yo man with a  pmhx of COPD who noted a recent eruption of vesicles on trunk, as well as his forehead and scalp. No fever. No other pertinent history. No itch. No pain. No new meds.
It started as blisters on the trunk, slightly itchy but no other symptoms, and not painful. The lesions opened up with clear fluid being expressed and leaving shallow ulcers. They have started become generalized with new lesions on the scalp and genitalia.

O/E:  Lesions appear like small bullae/vesicles on chest and abdomen, with clear fluid. In the center is what appears to be a black point, probably the hair follicle. There is no erythema on or around these lesions. 

Clinical Photo:

 Diagnosis:  What are your thoughts?


  1. from Khalifa Sharquie, Baghdad, Iraq: This is the classical very early manifestation of pemphigus vulgaris.It often starts with early tense blisters as this disease is common problem in Iraq.

  2. I considered the possibility that this may be disseminated zoster. In that case, a Tzanck smear of a vesicle would be positive for multinucleated giant cells. Varicella in a 60 yo would be expected to have significant constitutional symptoms.

  3. from Warren Heymann, M.D.: Interesting case. The differential of course extends from primary blistering diseases to infectious etiologies. I would be concerned about varicella (was he on steroids for his COPD) and start him on valtrex (or other) while you are waiting for biopsy results for H&E and DIF

  4. from Professor Bhushan Kumar, Chandigarh, India: "The most probable diagnosis being considered for the case in question is Bullous Pemphigoid"

  5. Dr. Ong Cheng Leng from Malaysia: "
    My comments:- most probably Bullous Pemphigoid as everything fits. Patient needs therapy as soon as possible as in this case, it can be rapidly progressive leading to ill health."

  6. What is the followup on this patient? Was it bulls pemphigoid? Would pemphigus vulgaris produce such tense bullae>


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