Friday, September 23, 2011

Painful Brusing in a 29 yo Woman

Presented by Hamish Dunwoodie, MBBS
Moncton, New Brunswick, Canada

Abstract: 29 yo woman with one week history of painful bruising on thighs

HPI: The patient is an otherwise healthy 29 yo woman with a one week history of painful bruises on her thighs. Five years ago she had leucocytoclastic vasculitis of her lower legs and very mild proteinuria. A renal consult felt she probably had mild IgA nephropathy. This has cleared. Her only medication is paroxetine, which she has been on for three months. She denies any trauma. The patient is a single mother of two children (11 and 3 years old) and lives alone with her kids. She was in school recently but is now on disability for "seizures" (although she is on no antiepileptic medications at present). She has been assaulted by a boyfriend in the past, but denies trauma this time.

O/E: There is purpura of the lateral thighs bilaterally. No evidence of LCV any longer. The remainder of the cutaneous examination is unremarkable.

Clinical Photo:

Lab: CBC, Chemistries, Urine Analysis all normal save for trace + rbcs. No proteinuria any longer.

Diagnosis: This is most likely traumatic purpura in a young woman who is reluctant todivulge an accurate history. Gardner Diamond Syndrome (autoerythrocyte sensitization syndrome, psychogenic purpura) was considered as well.

Questions: What are your thoughts?

References: (Full Text Online)
1. Gardner-Diamond syndrome: Difficulties in the management of patients with unexplained medical symptoms. Meeder R, Bannister S. Paediatr Child Health. 2006 Sep;11(7):416-9.

2. Gardner-Diamond Syndrome: bruising feeling. Bostwick JM, Imig MW. Mayo Clin Proc. 2008 May;83(5):572. (This is a short article)

Wednesday, September 21, 2011

Traumatic Ulcer

Abstract: 40 year-old man with non-healing wound

HPI: The patient is a 40 yo man who sustained traumatic abrasions of his leg and arm from a motorcycle accident on May 31, 2011. He has a history of chronic vesicular dermatitis of hands and feet complicated by recurrent staphyloccal cellulitis of legs. The wound on his right knee became infected and he was hospitalized over the summer on two occasions for parenteral antibiotics and debridement. As a result of this wound he has lot his job and his family is living marginally.

O/E: September 14, 2011. There is a nine cm relatively clean ulcer over the right knee. It has shown no tendancy to heal over the past month.

Clinical Photograph:

Diagnosis: Ulcer right knee.

Questions: How would you approach this lesion so that the patient can heal and get back to work? At present, he is getting dressing changes a few times a week and there are no plans for further surgical interventions. It looks like this will take months to heal by secondary intention.

Follow-Up: 10/19/2011 I have seen the patient on two occasions since this posting. The ulcer is ~ 75% better with just daily dressing changes with Vaseline impregnated gauze. He has not needed any further antibiotics. I expect it will be completely re-epitheliazed in two to three weeks.

Sunday, September 11, 2011

Insect Bite Lymphangitis

Presented by Nai-Chien Yeat
Williams College, Williamstown, Massachusetts

Abstract: 20 year-old Malaysian college student with one day history of an itchy line on right arm.

Yeat's History:
I developed itchy welts all over my body shortly after moving into my new dorm room. A bite on my right wrist caused extensive swelling and intense itching within 24 hours of first discovery. Within 36 hours, a swollen, pruritic red streak extended from my wrist to my upper arm.
A bite on my left ring finger caused extensive swelling and intense itching within 24 hours. Within 36 hours, the swelling and itching had spread to the back of my hand.
After bumping into Dr. Elpern on the street, I started a course of antibiotics (Augmentin) and took antihistamines (Clarityne and Benadryl) to relieve the pruritus.

O/E: (DJE) I bumped into Mr. Yeat on Sunday morning, September 4th on the Williams College campus and he showed me his hands and arms. There were erythematous papules with some superficial crusts on the hands and a lymphangitic streak on the volar right arm extending towards the elbow. Other than pruritus, he felt well and had no fever.

Clinical Photos taken by Mr. Yeat

Diagnosis: Although initially I was concerned about a bacterial lymphangitis, I now think this is most consistent with lymphangitis secondary to insect bite rather than a sign of a bacterial etiology. Yeat knows the initial lesions are bites and he feels well otherwise. I suppose a bite could have been superinfected with strep, so the Augmentin makes sense; but it could also be based on another mechanism. There are a few pertinent references including one from the BMJ which Mr. Yeat found (# 2). I am not convinced this is from bedbugs as many types of arthropod bites apparently can cause lymphangitis. It's curious that so few cases have been reported. This may be because the patients appear to have a bacterial process, are treated with antibiotics and get better as they would over a few days even without the medications. It would be important to know if bed bugs have been found in his dormitory.

(Note from Yeat one week after onset: "The swelling has completely subsided, and you can barely see the red streak that the lymphangitis left behind."

Questions: Mr. Yeat and I will appreciate your thoughts. Do you feel the Augmentin was necessary? Have any of you seen similar cases?

Reference: Superficial lymphangitis after arthropod bite: a distinctive but underrecognized entity?
1. Marque M, Girard C, Guillot B, Bessis D.
Dermatology. 2008;217(3):262-7. Epub 2008 Aug 6.
BACKGROUND: Acute bacterial lymphangitis is a common occurrence after skin damage. This diagnosis is often made in case of red linear streaks after arthropod bites, leading to the prescription of oral antibiotics. In this setting, noninfectious superficial lymphangitis after arthropod bites, an eruption rarely mentioned in the medical literature, appears as a diagnostic challenge.
OBJECTIVE: Our purpose was to study the clinical and histopathological features of this underrecognized condition.
METHODS: We collected the observations of six consecutive patients seen between the years 2003 and 2006, who developed an acute linear erythematous eruption along lymphatic vessels, mimicking common bacterial lymphangitis. Standard histological examinations were completed by immunopathological staining using the monoclonal antibody D2-40, a highly selective marker of lymphatic endothelium. Extensive review of the literature about acute noninfectious superficial lymphangitis was performed. Results: The clinical presentation and histological findings excluded an infectious etiology and suggested superficial lymphangitis after an arthropod bite in all the observations.
CONCLUSIONS: This article analyzes the clinical and histological features of noninfectious superficial lymphangitis after arthropod bite, a benign underrecognized condition mimicking common bacterial lymphangitis. Physicians should be aware of this benign reaction to avoid the useless prescription of antibiotics.

2. BMJ Case Reports 2010; doi:10.1136/bcr.09.2010.3310
Acute superficial lymphangitis following pigeon mite bite
Parvaiz A Koul, Syed Mudassir Qadri Full Text Online.

Tuesday, September 06, 2011

Erythema multiforme major

Presented by: Dr. Henry Foong
Ipoh, Malaysia

Abstract: Five Year-old boy with E. multiforme

The patient is a 5 year old boy presented with 3 day history of fever and generalised skin eruptions. Apparently it started with superficial lower lip erosion and the next day he had high fever and generalised skin eruptions on trunk, the upper and lower extremities. There was no family history of similar skin problems.

O/E he was afebrile. Generalised erythematous macules and plaques were noted on the face, trunk and extremities. The lesions were distributed acrally. Some of the macules had sharp margin round shape with concentric rings within it. A vesicle was noted on the centre of the macules. Few typical round macules were noted on the palms and soles. Clinically he has erythema multiforme major

TWBC 14, 900 (N11.4% L75.4% E2%) ESR 19. Mycoplasma antibody is negative. He is now empirically on oral acyclovir and oral clarithromycin.

The most likely cause of the EM is HSV infection in this patient. Wonder if you would use systemic corticosteroids in this patient?