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Symptoms closely resemble "strep" throat but suspicion for Lemierre should run high when pharyngitis and fever persist.

Lemierre Syndrome: A Forgotten Disease

A 3-year-old boy is seen for unilateral swelling on the left side of the face, in front of and behind the left ear. Findings on examination of ears, oral cavity, and teeth are normal. He is afebrile (temp, 37°C [98.6°F]), cooperative, and in no distress. He is otherwise healthy. Past medical history includes 1 MMR vaccination.

The child is bright and alert and has no fever. The swelling is on the left side of the face only. Find other clues to a diagnosis in the accompanying video.  

3-Year-Old Boy With Unilateral Facial Swelling 

The mother of a 10-year-old boy brings him in for evaluation of his moles (which are all benign). During the visit, the mother asks about the lesions on the first 2 knuckles of his right hand; she initially noticed them several months earlier. The boy is otherwise healthy.

Clinical Topics

White Knuckles

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 

In this Patient Care year-end video series we feature interviews with leading physician scientists and principal investigators who discuss the most important clinical trials of the year with experimental drugs, devices, and procedures, the implications of findings for daily primary care practice, and the promise of these unique additions to patient care.

Expert Perspectives 2024: Treatment for Agitation in Alzheimer Disease with George Grossberg, MD

Welcome to Expert Perspectives 2024: Interviews with Key Opinion Leaders on Novel Therapeutics

In the interview series that begins with the video above, George Grossberg, MD, Samuel W. Fordyce professor and director of geriatric psychiatry in the department of psychiatry at Saint Louis University School of Medicine, discusses  advances in understanding the disruptive behavioral, or neuropsychiatric, symptoms that comprise agitation in adults with 

(AD). According to Grossberg, depending on the setting considered and the stage of Alzheimer 

, research suggests that a "minimum of 50% of patients are affected by the spectrum of agitated behaviors." Grossberg is among the leading researchers evaluating 

 to quell agitation that could replace the widespread off-label use of antipsychotic medications, which are associated with significant adverse events. 

Agitation in Alzheimer Disease: A Behavioral Snapshot with Geriatric Psychiatrist George Grossberg, MD

 (above) Grossberg emphasizes that recognizing the disruptive behaviors of agitation in less severe stages of AD, ie in adults with mild cognitive impairment, reflects an evolving understanding of the disease spectrum. Agitated-type behaviors "do become more common with disease progression, but we need to look for them throughout," Grossberg said.

For the other videos in the series, see: 

Pearls for Primary Care: How to Talk About Agitation in Alzheimer Disease with Caregivers

For Agitation in Alzheimer Disease, a Novel, Oral NMDA Receptor Antagonist Could be the Next Targeted Treatment

Treatment for Agitation in Alzheimer Dementia: Pipeline Preview with George Grossberg, MD

Agitation in Alzheimer Disease and Antipsychotics Used Off-Label are Not Meant for Each Other

Nonpharmacologic Options for Agitation in Alzheimer Disease Should Always Come First: Expert Insights

Environment is a Primary Nonpharmacologic Intervention to Reduce Agitation in Alzheimer Disease, Geriatric Psychiatrist Explains

Alzheimer Disease Insights: It's Not All About Cognition, Counsels George Grossberg, MD

Agitation-Type Behavior Occurs Across the Spectrum of Alzheimer Disease Severity, Advises Expert

Agitation affects at least one half of adults with Alzheimer disease; geriatric psychiatrist Grossberg explains the symptoms and new treatments in this year's video series. 

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 

In a retrospective cross-sectional study of 273 individuals with moderate-to-severe atopic dermatitis (AD), Chinese researchers found that nearly 1 in 4 experienced anxiety and 1 in 5 had symptoms of depression, with both conditions significantly linked to worse disease severity and impaired quality of life. Independent risk factors for these psychiatric symptoms included lower education level, frequent medical visits, sleep disorders, allergic comorbidities, and severe pruritus. 

The findings, according to the authors, underscore the importance of routine mental health screening and integrated care strategies in the management of AD.

"In the clinical diagnosis and treatment of AD, it is crucial to adhere to a holistic approach that treats both the body and mind. This includes assessing the psychological state of patients and implementing psychological interventions to alleviate symptoms of" compromised mental health, corresponding author Kun Liu, PhD, of the department of dermatology, Shanghai Jinshan Tinglin Hospital, and colleagues wrote. 

AD has been consistently linked to increased rates of declining mental health, particularly anxiety, depression, and suicidal ideation.

 Meta-analyses have shown that adults with AD are more than twice as likely to experience depression and anxiety compared with those without the disease, a chronic condition characterized by intense pruritis and recurrent eczematous lesions.

 Despite this emerging data suggesting this strong bidirectional relationship between the dermatologic and psychiatric domains, clinical attention continues to be suboptimal, according to Liu et al.

Depression and anxiety affect as many as 1 in 4 people with AD, with pruritus, sleep disorders, education level, and comorbidities identified as independent risk factors.  

Vincent J Stravino, MD

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