Thorny, Horny Dilemma

Ian McColl from Queensland, Australia, is presenting a five year-old girl for opinions. He doesn't have much information at this time. We will present her case formally on VGRD in a week or two, but I know he'd appreciate rapid responses at this time, too.

Ian writes:
"She had been seen elsewhere for treatment of her "severe psoriasis" which she had for the last two years. Clinically this is chronic mucocutaneous candidiasis. There is no family history. She has had vaginal candidiasis before and UTIs. She is otherwise well. She did have shotty glands in neck, groin and axillae.

Has anyone had recent experience of treating a case? Ketoconazole orally ? toxicity? Fluconazole orally? How long for? Best wishes, Ian."

Case from Inuvik

From Alex Wong, PGY II Internal Medicine, UAB, Calgary:
I'm currently on a rotation up in the Northwest Territories and I just came back from a three-day travel clinic in Inuvik. We were asked to consult on a 40 yo woman who essentially has wide-spread rash. Was wondering whether you guys had any ideas.
Hx and O.E: Sudden-onset maculopapular pruritic rash on the trunk (both front + back) and upper extremities including hands, no obvious triggers or contacts according to the GP. Tried steroid cream + Benadryl with no effect, used Prednisone and cleared almost immediately. Took the Prednisone away and immediately came back, so restarted the Prednisone a second time and tried to taper off slowly this time... again, when Prednisone was taken away, rash came back (although during taper apparently she didn't have any symptoms.
Biopsy:They got a skin biopsy, and unfortunately don't remember the exact details of the biopsy (sorry), except that it raised the possibility of SLE.
Lab: GP did ANA, which was positive. Subsequently did C3/C4 + dsDNA, which were negative.
Steroids being slow-tapered again, and she had no rash when I saw her yesterday afternoon. She works on/off as hotel housekeeper, but insists no new contacts / cleaning products.
Your thoughts would be greatly appreciated.

'Tis the Season

A 78 yo man with a history of non-melanoma skin cancer presented today for a general skin exam: a six month check-up. It is high spring now and everyone is outdoors doing something. On his left mid-back I spied this unusual "tumor." The patient was unaware of it. He was pruning apple trees two days ago.



If he hadn't come in for a routine exam, who knows when this would have been discovered.

I pulled the tick out with forceps, gave him 200 mg of doxycycline to take and will see him back as necessary.

Strange and stranger. What some call an "incidentaloma."