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.

Derm round 16

Diagnosis?
Acute generalized erythematous pustulosis (AGEP).

The above patient was admitted for an elective surgery of left obstructive uropathy due to ureteric calculi. On third day, she developed spiking temperature in the ward, and thus the procedure was cancelled. She was empirically started on IV Cefoperazone. She then developed the above small pustular lesion over the limbs as well as some scattered lesions over the trunk after two days. Blood investigations were unremarkable.

On review of her old notes, she was diagnosed as having AGEP two months before, and responded to a course of oral Itraconazole.

Assuming that she might be having similar candida infection, she was prescribed Itraconazole again. However, the lesions resolved completely the next day before Itraconazole was managed to be given. The antibiotic was stopped and she became afebrile.

Is the AGEP due to Cefoperazone or due to infection?



More:
AGEP due to herbal remedy.
IJDVL.
Archieve of Dermatology.
RegiScar Project.
Rev. Inst. Med trop. S. Paulo.
Dermatology Online Journal.
Medscape.

Derm round 15

Case 1


14 years old girl, had the above lesions since birth.

Diagnosis?
Congenital nevomelanocytic nevus, giant.

See also:
Congenital nevi.


Case 2
45 years old gentleman presented with the above pruritic lesion over the scrotum. Fungal scrapping was negative.

Diagnosis?
Lichen simplex chronicus.

Derm round 14

This eight years old boy has the above non-pruritic scalp lesions since infancy. He currently presented because the mother noted significant hair loss of one month duration. The lesions are very scaly plague with ill-defined borders. Wood's lamp and fungal scrapping were negative.

What is it?
I treated the patient for Seborrheic capitis (seborrheic dermatitis of the scalp).

Derm round 13

This 9 years old girl, presented with the above non-pruritic lesion of 2 months duration. It is a well-defined, slightly erythematous and scaly lesion. Wood's lamp was negative and fungal scrapping was negative.

What is it?
? Pityriasis alba.

What other differentials?

By the way, I gave her Hydrocortisone ointment.

Pompholyx

19 years old student presented with the aboce very pruritic small vesicular lesions of both hands of two days duration.

Diagnosis?
Acute eczema, dyhidrotic eczematous dermatitis, vesicular palmar eczema.

Chromoblastomycosis

62 year old man presented to us in 2003 with the above lesions over his left lateral thigh region of nine years duration.

(The hyperpigmented areas are actually healed, photo taken 4 years after started on treatment).

The HPE was reported as:
Section shows skin tissue with central, irregular, benign, stratified squamous epithelial layer exhibiting acantholysis and mild pseudoepitheliomatous hyperplasia. The upper dermis shows presence of scattered, suppurative granulomas with neutrophils, multinucleated giant cells and ingested, pigmented "chest nut brown" rounded refractile fungal bodies. In addition, the dermis shows presence of numerous lymphocytes and plasma cells. Intrepretation: Chromoblastomycosis.

We repeated our own specimen and our HPE was reported as:
Section showing mild hyperplasia of squamous epithelium with foci of granulomatous inflammation in the superficial dermis. Scattered multinucleated cells are seen. The dermis is infiltrated by neutrophils and lymphoplasma cells. No fungal bodies identified in this specimen. Interpretation: Chronic granulomatous inflammation, consistent with fungal infection.

He was started on C. Itraconazole 200 mg OD till now. The lesion has improved more than 50%.
The question is, how long should we continue with the anti-fungal treatment?

Papular eczema

8 years old girl presented with the above very pruritic papules over her forearm and hands of 5 years duration. She was very embarrassed and depressed because her classmates made fun of her and refused to befriend her.

Derm round 12

30 years old man presented with the above lesions over the supra-pubic/base of penis since the age of 18 years old (12 years). He denied history of sexual exposure when he first had the lesions.

These lesions looked something like this one too.

What is the diagnosis?
?Viral wart.

Below, I included some viral wart pictures from DermNet.com:

Derm round 11

65 years old lady presented with the above lesions over the face of 6 months duration.

What are these lesions?
? Granuloma faciale.

We did a biopsy and the result came back as such:
" Multiple sections showed skin tissue with marked granulomatous lesion in the dermis consists of aggregates of epitheliod cells, lymphocytes and some multinucleated giant cells. No obvious central caseous necrosis seen. No atypical cell seen. No evidence of malignancy seen. Stains for fungal, AFB and leprae bacilli are negative. Diagnosis: Chronic granulomatous lesion, suggestive of atypical mycobacterial infection."

Hmn, rather non-specific isn't is?
What features actually point to atypical mycobacterial infection, huh?
Anyway, we will discuss the case in the HPE discussion session with the pathologists cm.

Derm round 10

The same lady with ?deep fungal infection (Derm round 4, case 2), was discharged and followed up in the clinic. The initial swab C&S grew Staphylococcus aureus (Sensitive to Cloxacillin). She was treated earlier with IV Unasyn and Metronidazole for one week. She had also been given two weeks of oral Cloxacillin.

Currently, the lesions appeared to have dried up, but her left foot was still edematous. There were thick scale-like lesions on her left foot, which bled on removal of the scales.

Still unsure what this lesions were due to. I was comtemplating to do a skin biopsy next.

Derm round 9

20 years old gentleman presented with the above slightly painful, pruritic and smelly lesions over the the soles of three days duration. He is a kitchen helper.
Fungal scrapping was negative.

What is it?

? Pitted keratolysis as well.
I gave him a course of oral Erythromycin, KMNO4 soak and anti-fungal cream.

Fixed drug reaction

This gentleman developed the aboved lesions within 12 hours of taking Paracetamol for high grade fever. Review of his case notes, actually documented that he had history of allergic to Paracetamol. According to the patient, he felt terrible because of the fever and took the medication despite the known allergy.

What other alternative if the patient has allergy to Paracetamol?

Derm round 8

25 years old lady presented with the above lesions over the posterior neck region of 5 years duration.

The lesions appeared warty or cauliflower-like.

What is it?

?Viral wart.
?Epidermal naevus.