Erythema Migrans with Pustules

This 27 yo woman was sent from the E.R. with a 5 day history of a solitary 20 cm annular plaque on the right hip. It looks classical for erythema migrans (EM) of Lyme disease. Her three year-old daughter had a tick on her skin 2 weeks ago, but she has no history of tick bite. The patient is well otherwise.
Photos taken June 24, 2008


Clinically, this is Lyme disease, but no reports in literature of pustules. There is one from China with vesicles (which these may have been initially).

Lyme titers are pending (but this is a clinical dx at this point) and a culture of a pustule was taken.

E.R. doc put her on cefuroxime because she can't tolerate doxycycline (bad GI upset). She has a f/u appointment in a week.

Ranula

Abstract: 16 mo girl with mucous cyst of lower lip.
HPI: This 16 mo Chinese girl presented for evaluation of a lip lesion that has been present for two months. It waxes and wanes in size. The lesion does not appear to bother her. Her mother speaks little English and is very worried about this lesion.
O/E: 6 mm translucent cyst lower lip
Clincal Photo:

Lab/Path: N/A
Diagnosis: Mucous Cyst (Ranula)
Questions: How would you approach this patient? I need to find a translator so that I can have a meaningful discussion with the child's mother. In the past, I have treated a few of these with liquid nitrogen and they did well, but that might be very traumatic for this child (and the mother). Might have to find a pediatric ENT (the closest would be ~ 75 miles from here)

Reference: There are two good chapters on eMedicine.com
and eMedicine2.com The latter is more detailed.

This is the largest study I found, and I'll write to the authors.
Clinical review.com2 of 580 ranulas.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Sep;98(3):281-7.
Zhao YF, Jia Y, Chen XM, Zhang WF.

CONCLUSION: Three patterns of ranula have similar clinical and histopathologic findings, although plunging ranula has some different clinical features. Removal of the sublingual gland via an intraoral approach is necessary in the management of various clinical patterns of the ranula. Recurrence rates of ranulas of any type are excessive unless the involved sublingual gland is removed.

Man from Mauritius

Presented by Dr. Philip Li Loong, Quatre Bornes, Mauritius

Abstract: 27 year old man with four year history of a papular eruption.

HPI: This man's lesions began on the face four years ago and later developed in the groins and axillae. Initially macules, they became papular and much more numerous. At onest, they were felt to be verruca plana. Cryotherapy was tried without success.

O/E: The lesions are 2 - 3 mm in diameter brown to yellowish papules. Distribution: Face, crural folds, axillae.

Clinical Photos:





Lab: Full blood count normal, cholesterol 5.2 upper limit, triglycerides normal, LDL HDL also normal, Immumoglobulins normal, plasma electrophoresis normal, thyroid function tests normal.
Pathology: Two biopsies were done.
The first showed a mild chronic inflammatory infiltrate in the upper dermis made up of small lymphocytes and histiocytes with occasional macrophages.
Repeat biopsy from the right axilla was reported as aggregates of foam cells admixed with other histiocytes, lymphocytes and some fibroblasts: "appearance consistent with eruptive xanthomas"

Diagnosis: Do you think this man has xanthoma disseminatum?

Questions: This entity may be associated with paraproteinemia and mucous membrane involvement. Comments for diagnosis and management will be most welcome. What are your thoughts? What further would you do?