Presented by Makayla Powers, PA
HPI: This 20-year-old college student presented for
evaluation of a facial eruption. She states that
about one to two months ago, she developed a rash on
the face. And was evaluated at the health center and
she was given topical steroid cream. She used this for
about 2 weeks an noted improvement, but when she
stopped she it recurred and was worse. At the
same time, she developed a vesicular, erythematous
rash on the dorsal hands. Anamnesis reveals last summer
she had a
bullous rash on the lower extremities that was
treated with antibiotics.
No history muscle pain or weakness or other constitutional
symptoms. There is no significant family medical history.
Patient was born in Cambodia and moved to Louisiana
with her family when she was 15 years old. The eruption
on the face and hands has caused her significant discomfort
and she has difficulty sleeping.
Physical exam: On exam, patient has an erythematous,
crusted eruption on the lower half of the face on the cheeks,
lips, perioral area, chin and neck. Her dorsal hands show
erythematous crusted plaques over the joints of a few digits
suspicious for Gottron papules.
Photos:
Summer 2022
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April 2023
Subtle Nail Fold Image
Assessment and plan: We are concerned she has
dermatomyositis and ordered CK, ANA, CBC, CMP,
TSH, ESR, CRP. Pending results we prescribed
tacrolimus for her face as she stated she would like to
avoid oral steroids.
Update: When seen 3 days later the eruption on her face
and hands was improved. She had blood work done
and early results show an elevated CK of 3030 (nl < 145)
and ESR 39 and a negative ANA. (She is not a gym rat)
Her hemogram and chemistries age normal. CRP.
The lab tests with the physical findings are suggestive of
dermatomyositis. We discussed that with her and
she
agreed to start oral prednisone. She will avoid
sun exposure. It’s the end of the semester and final
exams are
looming, We have located an academic
dermatologist near her home and further workup will
be done when she returns there for the summer. We did
not want to
impact her life at the end of her academic
year.
Note: CK levels in dermatomyositis can range from
normal to >50,000.
Diagnosis: At this time, we favor dermatomyositis; but she
may have an undifferentiated collagen vascular disease or
some form of photosensitivity. We feel that a definitive
work-up can wait until she can be seen at a center with
more expertise than we have.
References:
1.
Morgan
DJ, et. al. Diagnostic Stewardship to Prevent Diagnostic Error. JAMA. 2023 Apr 18;329(15):1255-1256
Diagnostic
stewardship optimizes testing to reduce diagnostic error and improve
diagnosis.1,2 With better diagnosis, more targeted and effective therapy can be
initiated. Interventions used for diagnostic stewardship are built into the
clinical workflow and often use methods from behavioral economics to nudge
clinicians toward better decisions. Changes may be made to diagnostic testing
at the steps of test ordering, test performance, or results reporting.
2. Sontheimer RD, Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects. Dermatol Clin. 2002 Jul;20(3):387-408. PMID
Thank you,
