Challenging cases: Getting past the obvious

Las Vegas - Clinicians need to think of causes of disease that are not obvious and do more investigation when they are faced with challenging cases, says one professor of dermatology.

"These are cases that a dermatologist would see in his or her practice," Dr. Braverman says. "If the common causes of dermatological eruptions are not identifiable, then you should think of much less common causes. Try to determine what is underlying all of this. You have to persevere and do more studies."

Dr. Braverman gave the example of a young man who presented with painless paronychia of one finger which had not responded to antibiotic therapy. He was about to undergo incision and drainage in the operating room but a dermatologic consultant observed that he had split papules of syphilis at the corners of his mouth.

Dr. Braverman also treated two patients who presented with tender, often ulcerated, nodules on their legs. A biopsy indicated a lobular panniculitis characteristic of nodular vasculitis; however, the patients were otherwise asymptomatic. After ruling out forms of necrotizing vasculitis and causes such as tuberculosis, Dr. Braverman reflected on the otherwise asymptomatic status of his patients. He then considered the possibility of asymptomatic conditions such as silent Crohn's disease. He referred the patients to a gastroenterologist who made the diagnosis of Crohn's disease with imaging studies. After successful treatment with infliximab the skin lesions cleared and did not recur.

"Both dermatologists and gastroenterologists may not consider Crohn's disease when it is asymptomatic," Dr. Braverman says.

Not what is expected

With an increasingly diverse patient population, Dr. Braverman notes that clinicians may see patients who present with conditions that are not typically present in North America.

"A man from Vietnam was treated for asthma with oral steroids," Dr. Braverman explains. "He developed hives all over his body and wound up in the emergency room a month later. It was suspected that he had urticaria."

On closer inspection, however, it was revealed that the man had a pattern of cutaneous larva migrans, and strongyloides were isolated from the sputum. The patient was treated with an anti-helminthic agent.

"Sputum examination revealed that he had a worm infection," Dr. Braverman says. "This infection is more commonly seen in the population from southeast Asia."

In another case, a 17-year-old female high school senior presented with a recurring linear blister formation on her legs under the top of high boots she wore. Before the blisters appeared the patient complained of a burning sensation. The patient had been coming for repeat visits to local dermatologists with this recurring eruption for about 18 months and denying any knowledge of its cause. At the time of referral, a biopsy had indicated the features of friction blisters. She then conceded that she had a habit of continually rubbing her pencil eraser on her leg, underneath her boot, where the blisters occurred.

"The patient was referred for psychological counseling," Dr. Braverman tells Dermatology Times.