An Incidental Finding

The patient is an 85 yo man who presented for generalized pruritus which has been present for two years. He has a history of prostate cancer and gastrointestinal bleeding. He's had a few transfusions over the past year or so and was concerned that they caused his itching.

He did not complain about his nose. I asked about it and he and his daughter gave this history: Three years ago he was hospitalized for pneumonia. He delvelped an inflammation of the ala nasi and was told it was "shingles." Biopsies were done and ruled out cancer. The left ala nasi was destroyed and this is how he healed.

Discussion. I wonder whether nasal oxygen was used and if the canula caused damage to the nose. It cold also have followed H. zoster. This is the picture that can be seen with Trigeminal Trophic Syndrome, a rare disorder that is thought to be traumatic in origin. Has anyone seen a similar picture and what are your thoughts.?

This is a good abstract:
Laryngoscope. 1988 Dec;98(12):1330-3.

Trigeminal trophic syndrome.

Arasi R, McKay M, Grist WJ.

Department of Dermatology, Emory University School of Medicine, Atlanta, GA.

Trigeminal trophic syndrome is an unusual condition also known as trigeminal
neurotrophic ulceration or trigeminal neuropathy with nasal ulceration. The
diagnosis is suggested when ulceration of the face, especially of the ala nasi,
occurs in a dermatome of the trigeminal nerve that has been rendered anesthetic
by a surgical or other process involving the trigeminal nerve or its central
sensory connections. A history of paresthesias and self-induced trauma to the
area further support the diagnosis. Neurological deficits causing trigeminal
trophic syndrome may result from surgical trigeminal ablation, vascular
disorders and infarction of the brainstem, acoustic neuroma, postencephalitic
parkinsonism, and syringobulbia. The following etiologies of nasal ulceration
should be excluded: postsurgical herpetic reactivation and ulceration, syphilis,
leishmaniasis, leprous trigeminal neuritis, yaws, blastomycosis,
paracoccidioidomycosis, lethal midline granuloma, pyoderma gangrenosum,
Wegener's granulomatosis, and basal cell carcinoma. In the case reported here,
the diagnosis of TTS was made primarily as a result of previous experience with
the syndrome, underscoring the importance of physician recognition of this
unusual disorder.

Tale of Two Lesions

I saw these two patients today. Your comments are most welcome. Path reports will be affixed when available.

1) 69 yo man with 1.5 month history of lesion right pinna. The lesion is slowly growing. The patient's son, a family doctor, asked him to make an appointment. This is a subtle lesion that could be a lentigo or a lentigo maligna. Two representative areas were biopsied.





















2) A 55 year-old priest whose parishioner noted a lesion on his left arm and asked him to see a doctor about it. He's been aware of this lesion for 3 months. It appears that the darkly pigmented papule began in a lentigo. I favor a diagnosis of melanoma here but this could be a seborrheic keratosis. An excisional biopsy of raised and macular portions was performed and based on pathology I will recommend further therapy.

Hypopigmentation in atopic dermatitis

This is a 7-year-old boy who developed multiple patches of hypopigmentation on the dorsum of the hands for 3 years. He had a history of atopic dermatitis and had severe eczema of the hands prior to development of the hypopigmentation on the hands. According to the mother, he had secondary infection with crusts formation on the hands. The lesions were patchy hypopigmented macules mainly on the dorsum of the hands and feet. There were no family history of similar pigmentation. Wood's lamp examination however showed accentuation of the hypopigmented lesions.

Based on history this is most likely post inflammatory. Other differential considered includes vitiligo. Vitiligo is probably unlikely in this patient as the hypopigmentation developed after he had eczema with secondary infection of the hands and feet.

Any suggestions for this hypopigmentation? Would UVB or tacrolimus ointment help?

Thanks for your comments.

A Case from New Brunswick

A friend from coastal New Brunswick sent this interesting case:

Dear Dr. Elpern,

The patient is a 91 year-old working lobsterman who was sent in by his GP for evaluation of a large fungating tumour on his left temple. By history, the lesion has been present for 15 years but has only really increased in size in the past 18 months. He's in vigourous good health otherwise.
On close examination, the tumour was found to be on a stalk. It's surface measured around 5 cm in diameter, whilst the pedicle was 9 mm in diameter.
After cleaning the area, I administered local anesthesia with lidocaine and epinephrine and snipped it off. I dissicated the base and applied a dressing.
I may follow-up with imiquimod (as recommended by a dermatologic friend) or may excise the defect secondarily.
We occasionally see dramatic tumours like this is watermen. They are a stoic lot.

I wonder, do your colleagues have any suggestions? I will post the path report when it is ready.

Cheers,

Dr. Hamish Dunwoodie, FRCSC
General Surgeon
Moncton, NB, Canada

Probably Lyme

The patient is a 56 year old man in good general health.
Six days ago, he developed an erythematous papule on the left abdomen.
Over the past week, this has grown into an oval 10 centimeter pruritic erythematous plaque.
This is a solitary lesion and the remainder of the cutaneous exam is unremarkable.
There is no history of tick bite, but this is an endemic area and the patient has an outdoor life-style.

I suspect this is Lyme Disease and that it is too early for serology to be helpful.
After discussion with the patient, he was started on doxycycline 100 mg bid.

(For interest, please see case of June 20th)