Weird fixed-drug eruption case.

[pipistrelle]

Hi! I messed up when registering for the site and it says I am pre-health, however I am M2. I'm interested in derm and am doing a project currently on fixed drug eruptions but need some guidance as I can't seem to find a coherent answer anywhere else. If an adult female presents with spontaneously appearing/disappearing lesions on the inner labia and associated dysuria that began 4 years ago but only recur every several months, last for 24 hours or less, and appear as one lesion at a time but the IGg blood test for HSV is negative...could this be an FDE? Let's say the woman started taking an anticonvulsant, for example (known for reactions) and the first eruption occurs 6 months-1 year after first taking the drug, is this possible to investigate? I wanted to explore drug eruptions beyond SJS and focus more on their occurrence in people who take the offending drug regularly/on a daily basis as opposed to occasional short-term antibiotics. Is this viable for a case study?

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[GoSpursGo]

Just about anything could be a fixed drug eruption… but you’re going to have a hard time publishing anything as a case report without an actual diagnosis, which is often tough to get to fly for derm pubs without a biopsy and some useful correlates.

This probably isn’t something you can crowdsource. If this is an actual patient at your institution you need to talk with a faculty mentor about how to approach the case, and more broadly about how to publish.

 

[LunaOri]

It’s not a fixed drug eruption.

 

[Hzreio]

Drug eruptions have unique presentations that are usually well documented. Just bc someone gets some symptoms and is taking a medicine that is known to cause SJS or DRESS doesnt mean that it's drug related

 

[OraclePL]

Hi! I messed up when registering for the site and it says I am pre-health, however I am M2. I'm interested in derm and am doing a project currently on fixed drug eruptions but need some guidance as I can't seem to find a coherent answer anywhere else. If an adult female presents with spontaneously appearing/disappearing lesions on the inner labia and associated dysuria that began 4 years ago but only recur every several months, last for 24 hours or less, and appear as one lesion at a time but the IGg blood test for HSV is negative...could this be an FDE? Let's say the woman started taking an anticonvulsant, for example (known for reactions) and the first eruption occurs 6 months-1 year after first taking the drug, is this possible to investigate? I wanted to explore drug eruptions beyond SJS and focus more on their occurrence in people who take the offending drug regularly/on a daily basis as opposed to occasional short-term antibiotics. Is this viable for a case study?

Need a biopsy. Many things fit that DDX.

 

[pipistrelle]

It’s not a fixed drug eruption.

What would you guess? Negative HSV blood test, normal Pap, normal pelvic. I'm so stuck

 

[pipistrelle]

Need a biopsy. Many things fit that DDX.

I considered putting this in there, but the marks come and go within minutes to hours. Extra complicated

 

[LunaOri]

What would you guess? Negative HSV blood test, normal Pap, normal pelvic. I'm so stuck

Urticaria?

 

[Tenk]

This sounds like something that would show up to my ER at 3 am.

 

[pipistrelle]

Urticaria?

No itching.

 

[TelemarketingEnigma]

What would you guess? Negative HSV blood test, normal Pap, normal pelvic. I'm so stuck

If these are your own symptoms you’re trying to work up, SDN is not the right place for a diagnosis. If this is a patient you are seeing with an attending, talk to them about the differential and additional work up that can be done! I’m not a dermatologist but the fixed drug eruptions I have seen do not disappear within minutes/hours

(Fwiw HSV blood tests are not gold standard for diagnosis, you need to directly sample a lesion of concern)

 

[Dral]

What TelemarketingEnigma said, as SDN is not for medical advice.

But to add, urticaria can be non-pruritic. Not much other than urticaria last less than 24 hours.

It's not FDE based on what you're telling us. If it's a drug eruption, it sounds like an urticarial drug eruption.

 

[pipistrelle]

If these are your own symptoms you’re trying to work up, SDN is not the right place for a diagnosis. If this is a patient you are seeing with an attending, talk to them about the differential and additional work up that can be done! I’m not a dermatologist but the fixed drug eruptions I have seen do not disappear within minutes/hours

(Fwiw HSV blood tests are not gold standard for diagnosis, you need to directly sample a lesion of concern)

Nah, not my symptoms. just a bit weird/unique and want to discuss/express befuddlement. True about HSV blood tests but pt had not had sexual contact for over a year when blood tested, so would it not be odd for HSV to evade detection at that date?

 

[Dral]

HSV serum tests should be able to tell if someone has ever been infected by HSV I or II. As mentioned, the best way to diagnose is to swab a lesion of suspicion and run the appropriate test (whether that be Tzanck, PCR, culture, etc).

HSV lesions will last longer than 24 hours but can certainly recur. EM lesion could be a response to HSV, but these will also last more than 24 hours. It could be urticarial med/drug vs urticarial contact derm vs other urticaria. I suppose you could throw autoimmune progesterone dermatitis (especially if they coincide with the patient's menstrual cycle) on the Ddx. However, again, not FDE from what you're telling us.

Proof of FDE in any lesion would be convincing clinical presentation (+/- convincing pathology) and cessation with removal as well as recurrence with re-challenge (if clinically feasible).

 

[pipistrelle]

HSV serum tests should be able to tell if someone has ever been infected by HSV I or II. As mentioned, the best way to diagnose is to swab a lesion of suspicion and run the appropriate test (whether that be Tzanck, PCR, culture, etc).

HSV lesions will last longer than 24 hours but can certainly recur. EM lesion could be a response to HSV, but these will also last more than 24 hours. It could be urticarial med/drug vs urticarial contact derm vs other urticaria. I suppose you could throw autoimmune progesterone dermatitis (especially if they coincide with the patient's menstrual cycle) on the Ddx. However, again, not FDE from what you're telling us.

Proof of FDE in any lesion would be convincing clinical presentation (+/- convincing pathology) and cessation with removal as well as recurrence with re-challenge (if clinically feasible).

Thanks, this was helpful. Again, PT had been celibate for nearly over a year when blood test was done, and it showed nothing. All other labs normal too. So interesting that these never last more than 24 hours--always 24 or less, sometimes minutes/seconds and then gone if i recall correctly. Didn't think about autoimmune stuff but this is a neat puzzle.

 

[pipistrelle]

HSV serum tests should be able to tell if someone has ever been infected by HSV I or II. As mentioned, the best way to diagnose is to swab a lesion of suspicion and run the appropriate test (whether that be Tzanck, PCR, culture, etc).

HSV lesions will last longer than 24 hours but can certainly recur. EM lesion could be a response to HSV, but these will also last more than 24 hours. It could be urticarial med/drug vs urticarial contact derm vs other urticaria. I suppose you could throw autoimmune progesterone dermatitis (especially if they coincide with the patient's menstrual cycle) on the Ddx. However, again, not FDE from what you're telling us.

Proof of FDE in any lesion would be convincing clinical presentation (+/- convincing pathology) and cessation with removal as well as recurrence with re-challenge (if clinically feasible).

PT also c/o one of these episodes where she noticed a bright red circle in the area of pain which seemed to have slight dried blood around it later, but went away also in 24 hours or less, almost like fisuratum, and reduced to skin-colored round lesion before disappearing completely by the next day. Nothing was observed on clinical exam but PT reported this incident started a day after routine self-examination, so contact dermatitis could be considered?

 

[pipistrelle]

HSV serum tests should be able to tell if someone has ever been infected by HSV I or II. As mentioned, the best way to diagnose is to swab a lesion of suspicion and run the appropriate test (whether that be Tzanck, PCR, culture, etc).

HSV lesions will last longer than 24 hours but can certainly recur. EM lesion could be a response to HSV, but these will also last more than 24 hours. It could be urticarial med/drug vs urticarial contact derm vs other urticaria. I suppose you could throw autoimmune progesterone dermatitis (especially if they coincide with the patient's menstrual cycle) on the Ddx. However, again, not FDE from what you're telling us.

Proof of FDE in any lesion would be convincing clinical presentation (+/- convincing pathology) and cessation with removal as well as recurrence with re-challenge (if clinically feasible).

And - one more interesting thing - PT says pain is only present when urine comes into contact with affected areas. Pain is severe, but ceases immediately when urine is not in contact. No burning afterwards or before. Did report one instance where there was a stinging sensation before, but the subsequent external dysuria lasted for a few seconds before vanishing and did not linger. It seems unusual for dermatoses that are not associated w/ lingering discomfort.

 

[LunaOri]

Have you ever seen a lesion on this patient, or is she self-reporting?
Arthropod assault is also a possibility, if the lesions are real.

 

[OraclePL]

As a dermatologist, I’m just going to say, it’s very, very hard to make a diagnosis just based on paragraphs of text.

Literally anything with eroded or inflamed skin could hurt when in contact with urine. You need to discuss with your attending. You won’t find an answer here.

 

[pipistrelle]

Self-reporting; the lesions never stay long enough to be seen.

Have you ever seen a lesion on this patient, or is she self-reporting?
Arthropod assault is also a possibility, if the lesions are real.