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.