People experiences provide the foundation for lifelong learning

New York - William D. James, M.D., considers a number of cases particularly memorable because of their instructive value during his active dermatology career, which has spanned some 25 years and encompassed patient care, research and education.

Delivering the Everett C. Fox, M.D., Lecture at the Summer Academy Meeting 2007 here, Dr. James took attendees on a "tour" of a series of clinical cases and the important lessons he learned from them.

Several cases relate to specific clinical pearls for diagnosis and treatment, but many provide a more general but fundamental message, he notes.

Dermatitis a teacher

Dr. James told attendees that several cases involving patients with allergic contact dermatitis taught him the value of thinking outside the box, challenging accepted practice and finding answers to questions through the best evidence that can be obtained.

One case involved a young man who had steri-strips applied over his knee surgery incision site. When an overlying cast was removed several weeks later, physicians observed a red, pruritic, vesicular eruption that was identified as an allergic reaction to colophony.

"This case led me to work with the steri-strip manufacturer to eliminate colophony from the adhesive formulation, and hopefully was important for helping other patients avoid developing this type of reaction," Dr. James says.

Experiences with a patient and his own son who developed severe allergic reactions after topical use of bacitracin ointment led Dr. James to question the safety and efficacy of antibiotic application to postsurgical wounds.

To reach an answer, he and colleagues undertook a randomized, double-blind, prospective study comparing bacitracin and white petrolatum for post-surgical care of more than 1,200 wounds in patients undergoing outpatient dermatologic procedures.

Based on the results, the investigators concluded white petrolatum was a safer, less expensive and equally effective choice for woundcare in this setting, and, as an added benefit, reduced selection of virulent organisms.

A far-reaching case

A case involving a military recruit who presented for basic training in seemingly good health and was found to harbor HIV infection taught him that even a single case can have far-reaching consequences.

Secondary to the effect of vaccination on his immune system, the recruit developed an ulcer at his smallpox vaccination site and subsequently disseminated vaccinia infection along with cryptococcal meningitis.

"We reported this case in the New England Journal of Medicine in 1987, when little was known about the natural history of asymptomatic HIV infection. It led the military to perform HIV testing of all active military personnel to protect the blood supply in the battlefield and of all new recruits to identify individuals with asymptomatic infection. Furthermore, it helped to extend the known epidemiologic and natural history factors of HIV infection," Dr. James says.

When results confuse

A case involving a West Point cadet on the wrestling team who presented for treatment of facial herpes gladiatorum reinforced the importance of keeping an open mind.

Culture of the cadet's lesion showed presence of the virus but also Escherichia coli.

Finding of the gram-negative organism was surprising, considering that its growth usually requires significant humidity. The patient was also receiving chronic oral antibiotic treatment for acne, and E. coli was recovered from his nose.

"Gram-negative folliculitis was diagnosed in this patient and a series of more than 30 others being treated for severe acne. Isotretinoin had just been released, and as a result of its mucosal drying effect, we found it was the treatment of choice for both clearing the acne and eradicating the E. coli," Dr. James says.