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1. The patient had just recovered from a sore throat and noticed discrete red nodules, which eventually coalesced into a single large edematous plaque over the right anterior tibia. The deep intradermal and subdermal edema is exquisitely tender to touch, considerably warmer than the surrounding skin, and highly blanchable.
Diagnosis: Erythema nodosum is a reactive form of septal panniculitis with many potential triggers. Notable triggers include Crohn disease flares and use of drugs such as sulfa, gold salts, and oral contraceptives. Several infections have been identified as triggers, including strep, mycoplasma, and campylobacter, as well as deep fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). More unusual causes include pregnancy and diseases such as sarcoidosis, tuberculosis, Behçet disease, and leukemia/lymphoma.
For more information, see “Painful Lesion Hasn’t Responded to Antibiotics.” Clin Rev. 2015;25(11):10,12.
For the next photograph, proceed to the next page >>
2. A 16-year-old high school student joins her friends in a 2K run one morning. The next day, her shins are so painful she can hardly walk. She applied ice packs to her legs, using elastic bandages to hold them in place until the ice cubes melt. As her legs rewarm, a rash appears where the ice packs contacted the skin.
Diagnosis: This condition is urticarial in nature—albeit an unusual form, triggered by cold. Though it appears counterintuitive, cold uriticaria typically appears only on rewarming of the affected area and is marked by the sudden appearance of “welts” or “hives” that usually clear (with or without treatment) within hours.
Uncomplicated urticaria resolves without leaving any signs (eg, purpura, ecchymosis) that might otherwise suggest the presence of a vasculitic component, such as that seen with lupus or other autoimmune diseases. Blanchability on digital pressure is one way to confirm benignancy, since blood tends to leak from vessels damaged by vasculitis, emptying into the surrounding interstitial spaces and presenting as nonblanchable petechiae, purpura, or ecchymosis. The relatively benign nature of this patient’s urticaria was also suggested by additional history taking, in which she denied having fever, malaise, or arthralgia. These are all symptoms we might have seen with more serious underlying causes.
Cold urticaria is one of the so-called physical urticarias, a group that includes urticaria caused by vibration, pressure, heat, sun, and even exposure to water. Thought to comprise up to 20% of all urticarias, the physical urticarias occur most frequently in persons ages 17 to 40. Dermatographism is the most common form, occurring in the linear track of a vigorous scratch as a wheal that manifests rapidly, lasts a few minutes, then disappears without a trace. Its presence is purposely sought by the examiner to confirm the diagnosis of urticaria (most often the chronic idiopathic variety).
For more information, see “Inexperienced runner develops leg rash.” Clin Rev. 2012;22(8):W3
For the next photograph, proceed to the next page >>
Source: PhotoStock-Israel / Science Source
3. Typically manifesting with edema, pruritus, warmth, and tenderness, this lesion is usually associated with a history of recent trauma or pharyngitis followed by malaise, chills, and high fever. The lesion is usually raised with a clear line of demarcation at the edge.
Diagnosis: Erysipelas, an acute infection of the skin and subcutaneous tissue, is caused by beta-hemolytic streptococci invading tissues via a disruption to the skin barrier. Streptococcus strains are susceptible to penicillin and 99.5% are susceptible to clindamycin. Associated comorbidities in erysipelas include diabetes mellitus, as well as hypertension, chronic venous insufficiency, and other cardiovascular diseases.
For more information, see “Painful rash on face.” J Fam Pract. 2010;59(8):459-462.
For the next photograph, proceed to the next page >>
Source: CDC Public Health Image Library.
4. This patient presented with a red, expanding rash on the lateral aspect of the left thigh. Affecting any part of the body, this illness may present with fever, chills, sweats, muscle aches, fatigue, nausea and joint pain. Some patients have a rash or Bell’s palsy.
Diagnosis: Lyme disease, caused by B. burgdorferi bacteria, is transmitted to humans through the bite of infected Ixodes ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. If left untreated, infection can spread to joints, the heart, and the nervous system.
Because its symptoms mimic many other diseases, diagnosing Lyme disease can be difficult. The diagnosis is based on symptoms, physical findings, eg, rash, and the possibility of exposure to infected ticks; laboratory testing is helpful if used correctly and performed with validated methods.
Treatment choice depends on the whether the disease is early or late. Most cases of early Lyme disease can be treated successfully with a few weeks of antibiotics.
For more information, see “Lyme Disease Presents Differently in Men and Women.”
1. The patient had just recovered from a sore throat and noticed discrete red nodules, which eventually coalesced into a single large edematous plaque over the right anterior tibia. The deep intradermal and subdermal edema is exquisitely tender to touch, considerably warmer than the surrounding skin, and highly blanchable.
Diagnosis: Erythema nodosum is a reactive form of septal panniculitis with many potential triggers. Notable triggers include Crohn disease flares and use of drugs such as sulfa, gold salts, and oral contraceptives. Several infections have been identified as triggers, including strep, mycoplasma, and campylobacter, as well as deep fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). More unusual causes include pregnancy and diseases such as sarcoidosis, tuberculosis, Behçet disease, and leukemia/lymphoma.
For more information, see “Painful Lesion Hasn’t Responded to Antibiotics.” Clin Rev. 2015;25(11):10,12.
For the next photograph, proceed to the next page >>
2. A 16-year-old high school student joins her friends in a 2K run one morning. The next day, her shins are so painful she can hardly walk. She applied ice packs to her legs, using elastic bandages to hold them in place until the ice cubes melt. As her legs rewarm, a rash appears where the ice packs contacted the skin.
Diagnosis: This condition is urticarial in nature—albeit an unusual form, triggered by cold. Though it appears counterintuitive, cold uriticaria typically appears only on rewarming of the affected area and is marked by the sudden appearance of “welts” or “hives” that usually clear (with or without treatment) within hours.
Uncomplicated urticaria resolves without leaving any signs (eg, purpura, ecchymosis) that might otherwise suggest the presence of a vasculitic component, such as that seen with lupus or other autoimmune diseases. Blanchability on digital pressure is one way to confirm benignancy, since blood tends to leak from vessels damaged by vasculitis, emptying into the surrounding interstitial spaces and presenting as nonblanchable petechiae, purpura, or ecchymosis. The relatively benign nature of this patient’s urticaria was also suggested by additional history taking, in which she denied having fever, malaise, or arthralgia. These are all symptoms we might have seen with more serious underlying causes.
Cold urticaria is one of the so-called physical urticarias, a group that includes urticaria caused by vibration, pressure, heat, sun, and even exposure to water. Thought to comprise up to 20% of all urticarias, the physical urticarias occur most frequently in persons ages 17 to 40. Dermatographism is the most common form, occurring in the linear track of a vigorous scratch as a wheal that manifests rapidly, lasts a few minutes, then disappears without a trace. Its presence is purposely sought by the examiner to confirm the diagnosis of urticaria (most often the chronic idiopathic variety).
For more information, see “Inexperienced runner develops leg rash.” Clin Rev. 2012;22(8):W3
For the next photograph, proceed to the next page >>
Source: PhotoStock-Israel / Science Source
3. Typically manifesting with edema, pruritus, warmth, and tenderness, this lesion is usually associated with a history of recent trauma or pharyngitis followed by malaise, chills, and high fever. The lesion is usually raised with a clear line of demarcation at the edge.
Diagnosis: Erysipelas, an acute infection of the skin and subcutaneous tissue, is caused by beta-hemolytic streptococci invading tissues via a disruption to the skin barrier. Streptococcus strains are susceptible to penicillin and 99.5% are susceptible to clindamycin. Associated comorbidities in erysipelas include diabetes mellitus, as well as hypertension, chronic venous insufficiency, and other cardiovascular diseases.
For more information, see “Painful rash on face.” J Fam Pract. 2010;59(8):459-462.
For the next photograph, proceed to the next page >>
Source: CDC Public Health Image Library.
4. This patient presented with a red, expanding rash on the lateral aspect of the left thigh. Affecting any part of the body, this illness may present with fever, chills, sweats, muscle aches, fatigue, nausea and joint pain. Some patients have a rash or Bell’s palsy.
Diagnosis: Lyme disease, caused by B. burgdorferi bacteria, is transmitted to humans through the bite of infected Ixodes ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. If left untreated, infection can spread to joints, the heart, and the nervous system.
Because its symptoms mimic many other diseases, diagnosing Lyme disease can be difficult. The diagnosis is based on symptoms, physical findings, eg, rash, and the possibility of exposure to infected ticks; laboratory testing is helpful if used correctly and performed with validated methods.
Treatment choice depends on the whether the disease is early or late. Most cases of early Lyme disease can be treated successfully with a few weeks of antibiotics.
For more information, see “Lyme Disease Presents Differently in Men and Women.”
1. The patient had just recovered from a sore throat and noticed discrete red nodules, which eventually coalesced into a single large edematous plaque over the right anterior tibia. The deep intradermal and subdermal edema is exquisitely tender to touch, considerably warmer than the surrounding skin, and highly blanchable.
Diagnosis: Erythema nodosum is a reactive form of septal panniculitis with many potential triggers. Notable triggers include Crohn disease flares and use of drugs such as sulfa, gold salts, and oral contraceptives. Several infections have been identified as triggers, including strep, mycoplasma, and campylobacter, as well as deep fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis, and sporotrichosis). More unusual causes include pregnancy and diseases such as sarcoidosis, tuberculosis, Behçet disease, and leukemia/lymphoma.
For more information, see “Painful Lesion Hasn’t Responded to Antibiotics.” Clin Rev. 2015;25(11):10,12.
For the next photograph, proceed to the next page >>
2. A 16-year-old high school student joins her friends in a 2K run one morning. The next day, her shins are so painful she can hardly walk. She applied ice packs to her legs, using elastic bandages to hold them in place until the ice cubes melt. As her legs rewarm, a rash appears where the ice packs contacted the skin.
Diagnosis: This condition is urticarial in nature—albeit an unusual form, triggered by cold. Though it appears counterintuitive, cold uriticaria typically appears only on rewarming of the affected area and is marked by the sudden appearance of “welts” or “hives” that usually clear (with or without treatment) within hours.
Uncomplicated urticaria resolves without leaving any signs (eg, purpura, ecchymosis) that might otherwise suggest the presence of a vasculitic component, such as that seen with lupus or other autoimmune diseases. Blanchability on digital pressure is one way to confirm benignancy, since blood tends to leak from vessels damaged by vasculitis, emptying into the surrounding interstitial spaces and presenting as nonblanchable petechiae, purpura, or ecchymosis. The relatively benign nature of this patient’s urticaria was also suggested by additional history taking, in which she denied having fever, malaise, or arthralgia. These are all symptoms we might have seen with more serious underlying causes.
Cold urticaria is one of the so-called physical urticarias, a group that includes urticaria caused by vibration, pressure, heat, sun, and even exposure to water. Thought to comprise up to 20% of all urticarias, the physical urticarias occur most frequently in persons ages 17 to 40. Dermatographism is the most common form, occurring in the linear track of a vigorous scratch as a wheal that manifests rapidly, lasts a few minutes, then disappears without a trace. Its presence is purposely sought by the examiner to confirm the diagnosis of urticaria (most often the chronic idiopathic variety).
For more information, see “Inexperienced runner develops leg rash.” Clin Rev. 2012;22(8):W3
For the next photograph, proceed to the next page >>
Source: PhotoStock-Israel / Science Source
3. Typically manifesting with edema, pruritus, warmth, and tenderness, this lesion is usually associated with a history of recent trauma or pharyngitis followed by malaise, chills, and high fever. The lesion is usually raised with a clear line of demarcation at the edge.
Diagnosis: Erysipelas, an acute infection of the skin and subcutaneous tissue, is caused by beta-hemolytic streptococci invading tissues via a disruption to the skin barrier. Streptococcus strains are susceptible to penicillin and 99.5% are susceptible to clindamycin. Associated comorbidities in erysipelas include diabetes mellitus, as well as hypertension, chronic venous insufficiency, and other cardiovascular diseases.
For more information, see “Painful rash on face.” J Fam Pract. 2010;59(8):459-462.
For the next photograph, proceed to the next page >>
Source: CDC Public Health Image Library.
4. This patient presented with a red, expanding rash on the lateral aspect of the left thigh. Affecting any part of the body, this illness may present with fever, chills, sweats, muscle aches, fatigue, nausea and joint pain. Some patients have a rash or Bell’s palsy.
Diagnosis: Lyme disease, caused by B. burgdorferi bacteria, is transmitted to humans through the bite of infected Ixodes ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans. If left untreated, infection can spread to joints, the heart, and the nervous system.
Because its symptoms mimic many other diseases, diagnosing Lyme disease can be difficult. The diagnosis is based on symptoms, physical findings, eg, rash, and the possibility of exposure to infected ticks; laboratory testing is helpful if used correctly and performed with validated methods.
Treatment choice depends on the whether the disease is early or late. Most cases of early Lyme disease can be treated successfully with a few weeks of antibiotics.
For more information, see “Lyme Disease Presents Differently in Men and Women.”