Have a mind blowing case for you guys!

[Param]

Hi everybody!

This is a very interesting case that I chanced upon & till date no diagnosis as yet. See if you bright chaps can nail it!

50 year old Asian female moved from San Francisco to Los Angeles in early Jan 2002. Two months later she started developing rashes and generalized pruritis all over the body. The sun made her skin itch & burn & everytime she had a shower her body burned and then itched.

The first dermatologist who saw her said that this is eczema and prescribed Pred 20mg daily X 10 days (no tapering), Triamcinolone acetonide ointment & Atarax 5mg hs.

The second derm. guy said. " Oh no, this is not ezcema but its Lichen Planus." He wanted to start her on Griseofulvin but since he himself could not say for sure that this treatment will work the patient refused to take Griseofulvin. He too added Pred & another steroid oinment.

Both the drs did not do a biopsy as the pt did not have insurance. Meantime as long as she took the steroids she "seemed" to get better but never really recovered. The pt is in severe agony as she is unable to sleep at nights and has quit her job. The itching & burning is so unbearable that the areas that she has scratched like the axilla, popliteal fossa region, under the breasts and inguinal regions have now become lichenified and darkened in color.

She had the whole battey of tests done including the thyroid panel, FSH, LH , liver function tests, urine etc.

The only bad picture was the following:

Hemogram(without platelets)
WBC 12.2 (high)
RBC 4.69
HEMOGLOBIN 10.2 (low)
HEMATOCRIT 35.2 (low)
MCV 75 (low)
MCH 21.8 (low)
MCHC 29.1 (low)

Her Hb was 9.2 and she was started on slow release Fe after which you now see a reading of 10.2

If there are any other Ix that you would like to ask me do so. Its too lengthy for me to write it all down.

So guys what do you think? Take your time , but give me some good suggestions. She says that as long as the illness can be cured she is willing to spend the money she put aside for a rainy day!

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[ckent]

Mind blowing out-pt derm case posted in the IM forum? No offense, but this sounds more like an attempt to sollict internet "medical" advise for a family member then an actual case presentation. I stink at derm (never had a derm rotation), but I will take a crack at it with my book open. Anyways, you didn't do a very good job of describing the rash from a medical point of view, but based on the 2 dx your "case" was given, I would imagine that it is a pruitic, plaque that has spread from her trunk to her extremities. Does the rash effect her palms or soles of her feet? And does the rash only appear in areas which she has been scratching or can reach? If this is an actual case presentation and not someone just soliciting medical advise, the fact that she's asian and 50 yrs old immediately makes think of gastric carcinoma and some unusual presenation of acanthosis nigrans. If your case is willing to pay for something to get a definitive dx, I'd recc that she pay for skin biopsy. I can't imagine a biopsy being over say 200 bucks out of pocket. If this is just someone looking for unprofessional medical advise, I'd say that the most likely dx is probably either scabies or some allergic reaction to something. You should suspect scabies if anyone else who lives with her has the same problem. You can look up the treatment for scabies on the internet. You can also try to figure out what has changed with her diet/medications and see if you can play around with that (try stopping new foods that she has been eating since coming to this country). I suspect that the mildly elevated white count was probably due to steroid demarginalization, and low hct was just due to an fe deficient anemia or unrelated problem (should consider checking stool for blood if she is post-menopausal and wants to). Anyways, these problems are best addressed with a doctor who can actually see the rash and knows her medical history.

 

[Renovar]

Seriously. You need to describe the rash and present the whole patient (ie. with PMH, SHX, Meds, FHX, ROS and Exam).

All I can gather from the above is that you have an Asian woman who has a pruitic lesion for like 1+ year now. Moderate relief from topical and oral steroids but not really doing much else. From the blood work, appears she has microcytic anemia (is she menopausal? is the patient heme +? Also, any iron study workup? THis can also be from anemia of chronic disease.) and a low grade systemic inflammatory response of unknown etiology (likely from steroids, though). The following is what I can come up with from the top of my head right at this second.

Infectious: Lymes disease, RMSF, secondary syphilis, HIV/AIDS, parasitic. What's the diff on that white count?

Systemic Vasculitis/ Rhematic: Lots of $hitz can do this from this category. Can explain midly elevated WBC count, and possibly anemia from chronic inflammation. Any OTHER complaints? ESR?

Neoplastic: Any of the primary cutaneous lesions (SCC, BCC, melanoma) are possible, so is cutaneous T cell lymphoma. Again, what does the lesion look like? Any constitutive symptoms, weight loss?

GI: Stool occult blood? GI symptoms? UC sometimes can present first with pyoderma gangrenosum.

Allergic interactions: Drug reaction? Is she taking any Asian herb? Very unlikely to be eczema if she doesn't have any history of such, or any history of asthma or allergic rhinitis.

Again, a whole panel of labs would be helpful.

 

[Param]

Dear ckent:

I was really disappointed that a person as intelligent as you is looking at the whole case as a family oriented pt and therefor they not wanting to pay for the treatment. Did you see my notes wherein I mentioned that both the derm Drs did not want to do a biopsy as she was uninsured?

Why is it posted in the IM site ? Because she was told that she may not actually be a derm case - they wanted to rule out SLE, ITP and many other options that they gave this pt.

You know ckent I can never understand the mentality of some people - why does a simple case have to be looked into as a complicated issue?

These forums are supposed to be for like minded doctors who share ideas and help each other - not always find faults & be quick to be judgemental about every topic thats listed.

If each doctor charges her $100-150.00 just for consultation and then lab work is extra - what can a pt who is jobless do? If I can help her in any way thats possible I will defintely do so. I am not going to preach to her about ethics - thats why they say that we are blessed with the noblest profession - because we show compassion for mankind.

I was told about this case at a dinner for old college mates. I thought there was nothing wrong in asking other drs for their opinion.

 

[Param]

Dear Renovar:

I will try & get more details about this pt. I know she is still menstruating & that the second derm. told her that she had hypochromic microcystic anemia.

The rashes started like an 'insect bite lesion' and as she continously scratched they became more of a macular/papular type.

She has always had a bad back which she treated with OTC medications especially Ibuprofen.

 

[IQ]

Based on the limited info presented, this lady probably has aquagenic pruritus with a ddx etiology of: polycythemia vera, myelodysplastic syndrome, and hyperesinophilic syndromes.
Presumptive tx of this condition should include: hydroxyurea, ASA, and antihistamines. However, patients with aquagenic pruritus secondary to PV often require phlebotomy.

 

[1996]

I really have nothing to add to her derm manifestations. However, for her anemia, since she is Asian descent, she might be a carrier of thalassemia trait, which would give her asymptomatic, mild, microcytic anemia. We did see some minor improvements in her Hgb with Fe, however, 10.2 is still below normal. Since she is asymptomatic, it is probably not very important. But if it is, indeed, thalassemia trait and not Fe deficiency, her Fe supplements should probably be stopped.

 

[DR]

Would like to see bili's. Pruritus with an initial low Hct would make me wanna see that. I thought about polycythemia initially, too...that story is classic for it, aside from the lesions...but the cell counts don't look like it. Scabies isn't impossible, either given the fact that it started in one spot looking like an "insect bite", and spread...and molluscum contagiosum is possible...but dermatologists should be able to diagnose both accurately. My two add-on comments would be to look at the biliary labs, look at new meds recently started (drug reaction?), and look at other labs, such as lytes, etc. to make sure this is not some kind of paraneoplastic manifestation, or any kind of early cutaneous T-cell lyphoma.

 

[seattledoc]

the key is what exactly occured in the beginning of this case. The initial history is where the diagnose will be made. If in the beginning, the complaint was "severe itching when I go in the sun or take a shower" then she has solar and aquagenic urticaria.

The easiest (and cheapest) way to diagnose each is to evaluate before and after exposure to the offending agent, e.g. apply water compress to skin and see what happens.

 

[Mike2]

Agree with checking biliary labs, especially alkaline phosphatase. If she has malabsorption due to diarrhea or not effectively secreting bile into the GI tract, that could explain Fe deficiency anemia. Additionally, consider that the condition "primary biliary cirrhosis" fits her demographic: middle-aged female. Frequently presents with nocturnal pruritus due to bile salts depositing in the skin. The connection between sunlight and shower water, I would wager, is the warmth (which can worsen itching by warming bile salt deposits in skin). Forget polycythemia vera since Hb and PLTs should both be up. The mild WBC elevation is probably related to steroids. Fun case.

 

[alin03]

hmmm.... para, you're either a 2nd year medical student or not in the medical field at all. "microcystic anemia" you wrote in your second post? there is no such thing my friend... and you were told about the "case" at a dinner for old college friends? wow... they memorized all that info? interesting.... my DX: i think this is a PBL case or something you have to do for school, and you're trying to get help with your "homework"