Dermatology

Abstract: A number of factors can contribute to a delay in the diagnosis of tuberculosis in pregnant women, including the presence of nonspecific symptoms, such as fatigue and cough; extrapulmonary manifestations; and asymptomatic disease. The diagnostic evaluation is the same as for nonpregnant patients and includes tuberculin skin testing and, when indicated, chest radiography (with appropriate shielding) and acid-fast bacillus stain and culture. Antituberculous therapy during pregnancy is generally safe and effective, although streptomycin should not be used because of the risk of vestibular or auditory damage to the fetus. For patients with active tuberculosis, treatment should be initiated as soon as the diagnosis is established. The treatment of latent infection is somewhat more controversial. The timing of the initiation of therapy is based on the risk of progression to active disease. (J Respir Dis. 2006;27(8):338-347)

Breast cancer, the most common cancer in women, is the cancer that most frequently spreads to the skin. A typical presentation is carcinoma en cuirasse, recurrent metastatic breast cancer that appears as nodules on the chest.

A 56-year-old man presented tothe emergency department with ahistory of constipation, abdominalpain, and blood-stained mucusdrainage from the rectum. The patienthad no fever; vital signs werestable. A vague fullness was felt in thelower abdomen. Rectal examinationrevealed anal warts; a patulous analsphincter; and a smooth, mobile, firmmass above the dentate line.

What are the consequences-if any-of not treating tineaversicolor?

Patients with allergic rhinitis are genetically predisposed to producing specific IgE antibodies in response to environmental allergens, such as tree, grass, or ragweed pollen or cat, dog, or dust mite allergens. Patients must have symptoms suggestive of allergies and positive skin or serologic test results that correlate with their symptoms.

A 31-year-old white woman presents with an erythematous skin eruption of 2 weeks' duration that consists of papules on the cheeks and several disk-shaped papules and plaques on the back, posterior neck, and right upper anterior chest.

A painful, vesicular eruption; an asymptomatic red macule; a rapidlyspreading erythematous plaque--can you identify the disorderspictured here?

Painful, 1- to 1.5-cm macules and papules had developed on the palms and dorsal hands and wrists of a 60-year-old man 2 weeks earlier, after a deer-hunting trip. He had not seen any ticks on his skin or clothing. The lesions persisted despite self-treatment with over-the-counter topical corticosteroids. The patient had general malaise but denied fever, chills, and arthralgia. He was not taking any medications.

A 22-year-old woman presents with fever and malaise of1 month’s duration. About 3 weeks earlier she went to theemergency department. Erythromycin was prescribed,and the patient was told to seek medical attention if hercondition did not improve. Since that time, her healthhas worsened, the fever has continued, and she has lostweight. She says she has had painful areas on her handsand feet but no rash.

Match each picture with the phrase below that best describes it. The organisms in these pictures might be microscopicor macroscopic, and they can be recovered from skin lesions or clothing by the patient and/or clinician.Answers and discussion appear on the following page.

Some sexually transmitteddiseases (STDs), such assyphilis and gonorrhea, arecenturies-old scourges; othershave attained clinicalsignificance only in recent years.Despite the availability of effectivetherapy for many of these diseases,they remain an important publichealth problem.

Abstract: Failure to recognize heparin-induced thrombocytopenia (HIT) can lead to devastating thrombotic events, including pulmonary embolism and stroke. In most cases, the problem develops within 5 to 14 days after a first-time exposure to heparin. HIT can occur with either unfractionated heparin or low molecular weight heparin (LMWH), but the incidence is much lower with LMWH. When HIT is suspected clinically, a functional assay and immunoassay should be performed. However, treatment should not be delayed while waiting for laboratory confirmation. All forms of heparin should be eliminated, and treatment with an alternative anticoagulant should be initiated to prevent new thromboembolic events. Argatroban and lepirudin are the direct thrombin inhibitors that have been approved for the treatment of HIT. Because of the risk of warfarin-induced venous limb gangrene or skin necrosis, warfarin should be avoided in patients with acute HIT until their platelet counts have recovered and they are improving clinically. (J Respir Dis. 2006;27(6):248-259)

Standard first aid for insect bitesand stings involves cleansing the skinwith soap and water followed byapplication of an antiseptic and topicaldiphenhydramine.

Green discoloration of the fingernailsdeveloped 6 weeks after a 29-year-oldwoman had artificial nails placed duringa manicure. The patient was a doctorof pharmacy degree candidate whowas married and had 2 children.

A 24-year-old woman complained of a rash on both feet and legs. She had also had intermittent pain in both ankles for the past year.

For the past few weeks, pruriticpatches have been erupting on a38-year-old man’s extremities. He recallsthat similar lesions occurredduring the last 2 winters. The patienthas a history of seasonal allergies;he owns a cat and 2 dogs.

A 6-year-old girl presents witha several-month history ofgenital discomfort that includesitching, irritation, andoccasional bleeding. Themother reports that there isblood on the toilet paper afterthe child wipes herself. Therehas also been some spottingin the child’s underwear. Thepatient seems to be grabbingat her crotch frequently.

To reduce the incidence of candidalinfections in patients with dermatologicproblems, instruct them to drythe affected area with a blow-dryeron a cool or warm setting before theyapply topical medications.

Test your knowledge of dermatology with 4 cases, 4 photos, 4 different rashes . . . which are the result of a drug reaction?

In 2 recent “Dermclinic” cases (CONSULTANT, December 2001, page 1812),Dr David Kaplan describes young women with lesions that arose on their extremitiesafter they used hormonal agents:

A 32-year-old woman tells you that she has had generalized weakness;swelling of the face, arm, and legs; diffuse myalgias; and a facial rashfor several weeks. Her main concern is her inability to keep her arms elevatedor get out of bed. Her history is significant for cervical cancer.

A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.

For 8 months, a 50-year-old woman had had an erythematous, pruritic rash on her palms. When her hands were exposed to water, the rash worsened and fissures developed. Recently, she noticed that the fissures had begun to bleed. Application of clobetasol, 0.05%, for 1 month provided no relief.

An 89-year-old hemiplegic man is seen for a routine physical examination. Major right brain stroke produced permanent dense left-sided motor deficit years ago. Has related vascular dementia.

A persistent, 2-month-old rash under both breasts has not responded to overthe-counter antifungal creams. The 55-year-old patient now seeks medical care;she is otherwise healthy.