Bizarre skin condition

Just want to share this interesting picture.
I read it in MMR.
Spotted in Unbounded Medicine.
Also in WFMU.

Derm round 24

45 years old lady presented with fever of 5 days duration, associated with chills, rigors, nausea, and bodyache. There was history of dengue outbreak in neighborhood. At day 5, fever resolved and the above rashes appeared mostly over her arms.

Clinically, multiple red spots with rim of halo noted over her arms. Full blood count showed leucopenia with lymphocytosis and thrombocytopenia, consistent with viral picture. Dengue IgM was positive.

Derm round 23

A 70 years old man was referred to the clinic for further management of multiple pruritic rashes over the body and lower limbs of two years duration.

The lesions over the body and lower limbs appeared well-demarcated erythematous rashes with scaling and excoriation. In addition, he has generalized skin dryness (xerosis).

I would have dismissed the case as 'another chronic eczema', until I find these lesions over the anterior chest.

A large ring-like lesion with central paling. There was reduced pin-prick sensation.

He also has this hand appearance, fixed flexion deformities of the right 4th and 5th fingers; suggesting of an ulna nerve lesion. The ulna nerve was thick on palpation. In addition, he has sparce eyebrows.

Slit-skin smears confirmed the diagnosis.
(Pic taken with my SE750)

eMedicine
WHO
Leprosy Review
DermNet NZ

Derm round 22

13 months old baby boy was admitted to the ward for prolonged fever. Clinically, he has hepato-splenomegaly. Full blood count showed pancytopenia. Peripheral blood film and the bone marrow aspirate were unremarkable. "Biohazard" screenings were all negative. Blood C&S has no growth and the rest of the investigations were unremarkable.

He was treated empirically with IV antibiotic (Cloxacillin and Ceftriaxone). After one week in the ward, and the temperature was still spiking, he developed numerous small papular lesions over the body and more marked over the lower limbs.

On examination, there were monomorphic, skin-colored, small papular eruptions, scattered over the face, body, upper limbs and numerously over the lower limbs (see pictures).

What is it?
We were thinking, more of molluscum contagiosum.

But the paediatricians thought otherwise, ? Gianotti-Crosti syndrome.

See:
eMedicine
DermNet NZ

Derm round 21

14 years old boy presented with the above lesions over the sole for 7 months.

Spot diagnosis?
See related post.

Derm round 20

27 years old gentleman presented with the above erythematous rashes over the malar region and alopecia of one year duration. There was no photosensitivity, oral ulcer or joint pain. Review of other system was unremarkable.

On examination, there was erythematous and slightly scaly lesion over the malar eminence as well as over the scalp. Similar lesions were also noted over the forearms and the back of trunk with areas of scarring. In addition, there was also scarring alopecia noted.

Diagnosis?
Discoid lupus.

More:
DermNet NZ
DermAtlas
BAD
lupus.org.uk

Derm round 19

50 years old gentleman, presented to me with the above lesions over his hands and feet of one month duration. He gave history of washing the floor mat with concentrated bleach solution three days before he started developing such lesions. He also stepped on the mat as well.

Clinically, the lesions appeared well-defined, dried and scaly with cracks, on an erythematous base. There were also maculo-papular rashes over the body. There was no scalp involvement or nail changes. Fungal scrapping was negative.

Although from the history, it sounded like contact dermatitis, clinically, the lesions appeared more "psoriatic". Furthermore, the lesions were more extensive and involved other non-exposure sites (body).

Diagnosis?
?Allergic contact dermatitis.
?Psoriasiform dermatitis.

Anyway, I treated him as having contact dermatitis.

Derm round 18

46 years old lady presented with the above very pruritic lesions over the body of two months duration. She is a hawker selling Char Koay Teow by the road side. On examination, there were extensive papular lesions over the forearms, lower limbs, neck and body especially over the sun exposed areas.

Diagnosis?
We are treating her as having some form of photodermatitis or polymorphic light eruption.

She was given Betnovate 1:6 cream, aques cream as emollient and anti-histamine. However, her response was unsatisfactory, with persistent disturbing pruritic lesions. One factor contributing to her condition was, she still works by the roadside and wear T-shirt with short pants despite been advice against doing so.

Any comment or suggestion?

More:
BAD
eMedicine

Update (On Derm round 1)

This lady presented with granulomatous lesions over the face of 6 months duration (Derm round 11). She had a skin biopsy done and was empirically covered with T. EES (Erythromycin) 400mg BD for two weeks.

Her biopsy was later reported as chronic granulomatous lesion, suggestive of atypical mycobateria infection.

On two weeks follow-up, surprisingly, the lesions had flattened >50% with areas of scaling and crusting.

We extended another two weeks of EES and will be discussing her HPE in the next combine meeting. KIV may need to start on anti-TB if indicated.

Derm round 17

50 years old gentleman, presented with right gluteal swelling of one year duration. The swelling bled easily on physical contact. He had symptoms of anaemia with loss of weight but normal apetite.

Clinically, the tumor is cauliflower-liked with ulceration and area of bleeding spots.

He was referred to dermatologist for opinion because of the HPE report:
Section showed skin with underlying spindle shaped illed-define lesion. The cells show a storiform pattern of arrangement. The cells have moderately pleomorphic muclei and few mitotic figures are seen. Foamy macrophages are noted with occasional large bizarre cells. The is no necrosis noted. There is no evidence of malignancy in this biopsy. Diagnosis: Benign fibrous histiocytoma.

However clinically, the lesion looked aggressive. There were multiple inguinal lymph nodes felt. No organomegaly felt. His Hb was 5.9 gm/dl. Other blood investigations were unremarkable. His chest X-ray was normal. CT scan of the lesion showed a soft tissue mass arising from the skin. CT scan chest/abdomen/pelvis revealed multiple lung nodules, inguinal lymphadenopathy and right ilium bone erosion.

In view of the clinical findings, this tumour behaved as malignant with evidence of metastasis.

A repeat biopsy was done on 13/2/2007.

Read:
Fibrous histiocytoma
Atlas of genetics and cytogenetics in oncology and haematology
GpNotebook
Malignant fibrous histiocytoma

Update (2/3/2007):
Repeat biopsy report:
Sections show skin tissue with underlying dermis. A diffuse cellular lesion is noted in the dermis. The lesion composed of spindle-shaped cells arranged in stori-form pattern. The spindle-shaped to plump cells exhibit mild to moderate pleomorphic vesicular nuclei and prominent nucleoli. Mitotic figures are seen. Infiltration by acute and chronic inflammatory cells is noted.
Immunohistochemical stain: The spindle-shaped cells are positive for vimentin.
Diagnosis: Dermatofibrosarcoma protuberans.