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A 59-year-old woman with chronic hepatitis C presented with abdominal pain that had grown progressively worse during the past 3 months.

Intracranial Bleeding From Cerebral Amyloid Angiopathy

This 13-year-old boy presents with hyperpigmented skin on his neck. He is 66.75 inches and weighs 232 pounds.

This 13-year-old boy presents with hyperpigmented skin on his neck. He is 66.75 inches and weighs 232 pounds. Your suspicion?

Clinical Topics

13-year-old With Hyperpigmented Rash

A 64-year-old woman with a history of basal cell carcinoma presents to the dermatologist for skin cancer surveillance. She is incidentally noted to have bruising on her upper eyelids (above). On questioning, she reports experiencing recurrent intermittent eyelid bruising for several years. She denies a history of trauma to her face, pain, or other associated symptoms.

Her medical history is significant for hyperlipidemia, hepatitis C (diagnosed >30 years earlier), osteoporosis, celiac disease, and idiopathic proteinuria for several years. Her surgical history includes appendectomy and carpal tunnel repair.

Pertinent family history includes her mother dying of multiple myeloma and her father of complications of diabetes.

Review of systems is significant for vague symptoms of gastrointestinal discomfort. On more directed questioning, she reports the eyelid purpura is temporally related to the Valsalva maneuver/ strained bowel movements. Her medications include atorvastatin, risedronate sodium, a daily multivitamin, calcium, vitamin D, and aspirin.

Her examination reveals no bruising elsewhere and no findings of interest on skin or mucous membranes.

B. Allergic contact dermatitis, purpuric type

Eyelid bruising was observed on a 64-year-old woman during routine skin cancer follow-up. She denied trauma or pain. What does this look like to you? 

Image IQ

Image IQ: Recurrent Eyelid Purpura 

The lesion on this 6-year-old boy occupies almost the entire left side of his nose. The mother attributed it to an injury her son had sustained 2½ weeks earlier, when he was hit in the face by a baseball.

Is this lesion the result of an injury, as the boy’s mother suspected, or something else?

Scaly Plaque on the Nose

A 13-year-old girl with known eczema presents with a vesicular rash on her palms that appeared after swimming in the ocean. Skin is tender; vesicles ooze clear liquid. Treated with triamcinolone w/o effect. Watch real-time examination on video.

A. Acute palmoplantar eczema (dyshidrotic eczema)

VIDEO: The child's hands are chronically dry but the skin has recently begun to crack; vesicular rash appeared after an ocean swim. Dx?

A 13-year-old Girl with a Vesicular Rash on Palms 

According to the World Health Organization, 

saves approximately 4 to 5 million lives annually. The remarkable number is supported by estimates published in the 

 in 2024 that vaccination against 14 different diseases saved 154 million lives over the past 5 decades.

 than age 5 years and of that group 101 million were infants younger than 1 year.

 Beyond the prevention of death, authors of the 2024 study found that 

 translated to an average of 66 years of full health.

While vaccination coverage for core immunizations among both children and adults in the United States remains high overall, recent CDC surveillance highlights notable disparities in uptake between states and population subgroups.

 Gaps in insurance coverage, logistical challenges, and misinformation are persistent barriers, continuing to impact communities unevenly and contributing to lower coverage rates in some regions and among specific demographic groups.

A recent study conducted by WalletHub examined the 50 states and the District of Columbia across 16 key metrics to see where Americans appear to be most responsible about getting vaccines. The data set ranges from the rates of children, teens and adults vaccinated against various diseases to the share of people without health insurance.

The findings presented in this PPT provide timely insights into these disparities and influencing factors by comparing states on three key dimensions: 1) Children & Teenagers Immunization Rates, 2) Adult & Elderly Vaccination Rates, and 3) Immunization Uptake Disparities & Influencing Factors. The data can inform clinicians, educators, and policymakers seeking to direct resources, strengthen outreach, and promote equitable protection against preventable illness.

Shattock AG, Johnson HC, Sim SY, et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. 

. 2024;43(10441):2307-2316. doi:10.1016/S0140-6736(24)00850-X

Vaccination coverage among adults in the United States, National Health Interview Survey, 2022. Centers for Disease Control and Prevention. October 4, 2024. Accessed September 12, 2025. https://www.cdc.gov/adultvaxview/publications-resources/adult-vaccination-coverage-2022.html

McCann A. States that vaccinate the most. September 9, 2025. Accessed September 9, 2025. https://wallethub.com/edu/states-that-vaccinate-the-most/66237

Northeastern states consistently ranked highest on measures including rates of flu vaccination across age groups, number of teens vaccinated against HPV, and older individuals with shingles vaccination. 

9 States Ranked Highest for Population Vaccination 

A 43-year-old woman presents to the dermatology clinic with complaints of a rash of one weeks’ duration. The first lesion started on the left breast (at right), then scabbed over. About 4 days later, fever, chills, neck pain, and headache abruptly started. The fevers spiked to 102°F. A tender rash then disseminated to involve the face, trunk, and extremities. She denies muscle or joint pain, vomiting, sore throat, diarrhea, or dysuria. The patient reports no other sick contacts.

She lives in an apartment in Brooklyn, New York, and denies recent travel. She works as a cook. She is monogamous with her male partner and lives with 2 children. The patient’s 2-year-old daughter has a similar lesion on her right thigh, but denies other symptoms. The patient had chickenpox in childhood and denies a history of herpes. On questioning, the patient reports that she had called an exterminator 2 weeks ago to deal with a “mouse problem.”

Physical exam is significant for an erythematous plaque with an eschar on one breast. Grey pustulovesicles on an erythematous base can be found on the dorsal hands (image at right), face, arms, legs, and flank. The oral mucosa is clear.

Rash began with one lesion followed by tender, disseminated eruption; fevers spiked to 102°F. Test your visual diagnostic skills. 

Image IQ: Rash with Chills, Neck Pain, Acute Fever  

Potjana Jitawatanarat, MD

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