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I had a case today of a guy with this rash:
It's a brown, maculopapular rash throughout most of his body that he's had for years. Anyone know what it is? Answer in 48 hours...
Al Borges, M.D.
My # 1guess is sarcoid. I note the "bark" like character of the skin in the right lower back. You term the rash brown, but he seems to be darker in complexion. I even wondered about Tinea Versicolor, but I have never seen it this 3 dimensional, and that rash is usually termed macular. The involvement of the scalp, and the relative protection in sun exposed areas suggests psoriasis. But clearly I am thinking out loud. I have never seen psoriasis look like this.
I agree it seems to spare the sun exposed area. As usual an Internist may want more history:
Past Medical problems: ?
History and PE: How long exactly, distribution looks like scalp, trunk, sparing sun exposed areas. Is it pruritic? Exact distribution -Involves palms, soles, arms, nail pitting? Are the lesions scaly, resolution is bad, looks scaly with patches - ie coalesced maculopapular rash.
Based on limited information, regional involvement and your specialty?
1. Cutaneous T cell Lymphoma
3. Guttate Psoriasis
4. Seborrheic dermatitis - unlikely too extensive on trunk
6. If it involves palms and soles will think of Syphilis and drug eruptions
Roger Ven Torres, M.D.
Praxis user since 2000
Well, the biopsy is still pending, but I'm pretty much 99% sure that it's Darier's Disease. Explanation from the NIH:
Darier-White disease (DD) is a rare, dominantly inherited disorder that is characterized by keratotic papules present predominantly in the upper trunk and scalp, palmo-plantar pits, and nail dystrophy. Atypical manifestations can mislead the diagnosis and include a predominantly flexural, acral or segmental pattern of involvement. We describe a patient with Darier-White disease who presented with a photo-distributed rash, and discuss the possible underlying mechanism. (URL: http://www.nsc.gov.sg/cgi-bin/WB_ContentGen.pl?id=452&gid=88)
This guy has had it all of his life, is relatively benign, non-pruritic, and there is no evidence for psoriasis (s.a. rashes on the extensor surfaces of joints), and involves the arms, legs, and scalp which are outside of the usually seen chest/back that is classic for Tinea Versicolor. It's just an ugly rash, which fortunately for him, has spared his face!
Sarcoidosis, lymphoma, etc would be associated naturally with underlying internal disease processes...
I did a google image search and I see that same picture here ... www.ucmh.sld.cu
My EMR is: Synapse It is what we know already that often prevents us from learning. Pioneers are the ones with the arrows in their backs.
Must have Munchausen's then if he's seeing multiple docs.
Synapse - the EMR for the superior physicianhttp://www.onhealthtech.com/Health Tech Discussion Board
On this case, I didn't take a picture as I didn't want to make the illness more than what it is to the patient. Sometimes taking out a camera can make the patient think that they have a cancer or something worse. Like the acromegaly picture, Google has exact likeness of the rash (the acromegaly picture was mine, since I had to send that one to UVA). If the biopsy shows otherwise, though, I'll put up the path picture.
I was the first doc he has seen with insurance! He's otherwise healthy so he has not seen too many docs along the way...
He's never been given the right diagnosis and has been given numerous lotions, creams, etc. most of which didn't do anything. He just needed reassurance that using possibly a mild soap and a cheap oily cream is enough.
WELCOME BACK AL!
I am glad you are back! Please keep us posted. I hope we can get CME credits with this thread. But at least we get a mental exercise beyond real world practice
Been trying to rack up 75 hours this year with MKSAP 14 and the other 75 next year till MKSAP 15.
Thanks for the welcome!
Anyhow, why not take on some medical students for the CME? I get 112 CMEs per year for teaching 2 GWU medical students per semester. (I used to mix it up with Georgetown students, but the GWU students generally were much brighter.)
Well we do have medical students rotating - 3rd and 4th year from the Medical College of Wisconsin, rotating for a month and my partner and I alternate so we get between 4 to 6 students a year each. But I do not believe we are credited for any CME units. Maybe I should inquire?
Yes you should! They even give you a little certificate...
gchiu:Must have Munchausen's then if he's seeing multiple docs.
That one had me laughing out loud. My kids came by to ask me what was so funny, but how do you explain it?
rheumdoc:That one had me laughing out loud. My kids came by to ask me what was so funny, but how do you explain it?
Typical Graham's medical joke ... though Al missed it
Erick, you made my day !
Is the biopsy results back yet?
I should be able to get it tomorrow.
BTW I got a new maculopapular rash- a real "tomato" of a patient, similar to this, but it's got ME stumped... I'll put it up tomorrow. My working diagnosis on this one include angioedema, lupus, or a possible malignancy. I've ruled out atopic rashes (food, soap, etc), and this one is not life-long. I've got great picks, too...