A Mysterious Rash Following Cardiothoracic Surgery: A Not So Sweet Ending.

A male in his 70s, with a recent history of aortic valve replacement, mitral valve repair, and permanent pacemaker implantation (PPM), developed a fever, raised inflammatory markers, and a disseminated rash. Despite being attributed a diagnosis of an unspecified connective tissue disorder and erythema nodosum at his local hospital, his symptoms continued to deteriorate. A subsequent urgent admission was arranged to his original cardiothoracic centre for the exclusion of infective endocarditis (IE). Although this was subsequently ruled out by echocardiography and microbiological evaluation, a diagnosis of Sweet syndrome (SS) was made following a punch biopsy of a skin lesion. This was later attributed to myelodysplastic syndrome following a bone marrow biopsy. In this report, we firstly describe our diagnostic algorithm for reaching this diagnosis and the characteristic skin lesions associated with this condition. We furthermore review the history of SS, its known associations, and treatment options.

Persistent Pruritic Linear Streaks of Adult-Onset Still's Disease: Reconsidering the Yamaguchi Criteria.

Objective Adult-onset Still's disease (AOSD) is a rare orphan disease, the diagnosis of which remains challenging. This study aimed to identify additional clues for establishing early diagnosis beyond the existing criteria. Methods A retrospective longitudinal cohort study was conducted at two community hospitals in Japan between March 2012 and December 2022. The clinical characteristics and medical histories of patients with AOSD were extracted from the clinical records. The primary outcome was to identify the key manifestations of AOSD for an early diagnosis beyond the existing criteria. Results Twenty-one patients (mean age, 58 years) were included in the study. Fever was the first symptom in 13 out of 21 patients (62%). Six out of 21 patients (29%) presented with a pruritic rash only, while two out of 21 (10%) initially presented with a sore throat. All patients visited more than one medical institution. The median time to reach a correct diagnosis was 41 days (IQR 19-138). Nineteen out of 20 patients (95%) exhibited a pruritic rash, identified as persistent pruritic linear streaks, with a median duration of 21 days (IQR 12-64) before the diagnosis of AOSD as a cutaneous manifestation. Conclusions Persistent pruritic linear streaks were a key feature in the context of an early diagnosis of AOSD, offering an option for reconsidering and revising the existing classification criteria.

Psoriasis Vulgaris Masked by Tinea Pedis in Two Unhoused Patients.

Psoriasis is a chronic inflammatory disease characterized by clearly marginated silvery plaques that affect men and women equally. Symptoms can vary among individuals; typically, it presents on the scalp, elbows, and knees. We present two cases of patients initially diagnosed with tinea pedis who showed no improvement with medical treatment. The first patient is an African American male in his 50s who arrived at a free clinic for unhoused persons with lesions to both feet initially diagnosed as tinea pedis. Although the patient was compliant with applying topical formulations of tolnaftate and clotrimazole, there was no discernible improvement in his symptoms and the skin lesions. After a thorough examination of the skin throughout the entire body, the diagnosis of psoriasis was considered. The patient started treatment with steroidal cream with improvement of the symptoms and lesions. The second patient is a Caucasian male in his 20s who also presented initially with complaints of a dry, intensely pruritic, and scaly rash on the dorsum of both his feet, as well as in between the digits of his feet for which an initial diagnosis of tinea pedis was also made. The patient remained non-compliant with treatment and, after reevaluation of his lesions along with an extensive survey of his body, was deemed to have psoriasis and prescribed topical hydrocortisone. The patient continued to remain non-compliant with his therapeutic regimen and subsequently developed cellulitis which is yet to resolve with treatment.

The diagnostic dilemma for atypical presentation of progressive human Mpox.

BACKGROUND: Human mpox has increasingly been reported worldwide since May 2022, with higher incidence in men who have sex with men (MSM) and persons living with HIV (PLHIV) with presentation typical for generalized macules and papules. CASE PRESENTATION: We are describing a case of human mpox, which presented as widespread, atypical round verrucous lesions that went undiagnosed in the community for six months and was treated with antibacterials and antifungals given the similarity to skin manifestations associated with endemic mycoses. CONCLUSIONS: Suspicion for human mpox should be high in young MSM and PLHIV who present with rash and mpox should be ruled out earlier.

An Uncommon Case of Syphilis With Simultaneous, Different Lesions: Moth-Eaten Alopecia, Syphilitic Keratoderma, and Psoriasiform Syphilis.

Syphilis is a re-emerging disease, and an increasing number of cases are being reported in Italy and worldwide. In this report, we present a case of a male patient with secondary syphilis characterized by the heterogenicity of the lesions: hyperkeratosis, psoriasiform-like lesions, papules, macules, and patchy alopecia on the scalp. The patient had applied several topical antimicrobials and steroid medicaments and taken oral acyclovir, which yielded no relief, for a previous wrong diagnosis. At the time of his presentation to our clinic, syphilis was suspected and confirmed by serology. The administration of a single intramuscular dose of penicillin led to a full recovery in three weeks. Screening for HIV and other sexually transmitted infections returned negative. Clinicians should maintain a high index of suspicion for syphilis when encountering sexually active patients with atypical skin manifestations.

Coexistence of Lichen Sclerosus Et Atrophicus and Morphea in the Same Lesion: A Case Report.

Lichen sclerosus et atrophicus (LSA) is an inflammatory dermatosis of unknown etiology, usually affecting the genital region, with extragenital involvement being uncommon. The coexistence of LSA and morphea in the same lesion is rare. The present study aims to demonstrate that LSA and morphea might share similar pathologic processes. We present a case of a 53-year-old female patient with extragenital lesions with clinical appearance and histopathological features of both LSA and morphea. Finally, the two diseases might lie on the same disease spectrum.

Multisystem Inflammatory Syndrome in an Adult Who Received Casirivimab-Imdevimab (REGEN-COV).

Multisystem inflammatory syndrome in adults (MIS-A) is a systemic inflammatory syndrome that presents with a heterogeneous collection of signs and symptoms in adults. Here we present a case of a 38-year-old male who met the case definition of the MIS-A four weeks after a mild, symptomatic case of coronavirus disease 2019 (COVID-19) despite receiving casirivimab-imdevimab (REGEN-COV). Given the presence of signs and symptoms consistent with MIS-A, the patient was started on intravenous immune globulin (IVIG) and IV methylprednisolone. He promptly demonstrated clinical improvement over the next several days.

Granulocyte Macrophage-Colony Stimulating Factor (GM-CSF) Induced Severe Atypical Rash in a Patient of Non-Hodgkin's Lymphoma.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) infusion has been reported with the development of transient maculopapular rash with spontaneous resolution. A 54-year-old Indian female developed intense erythematous generalised rash involving the face, trunk, extremities, palms and soles following GM-CSF infusion. Focal exudation and purpura were seen. Infusion was stopped and she was managed with a short course of systemic steroids. As yet, the development of such an atypical, severe rash following this cytokine infusion has not been reported in the literature.

Acute Generalized Exanthematous Pustulosis: A Painful and Pruritic Presentation of Pustulosis Following Pharmacotherapy for Pharyngeal Phlegmon.

Acute generalized exanthematous pustulosis (AGEP) is primarily a drug-induced skin eruption, which typically presents within two days of starting an offending medication; it is often self-limiting with spontaneous resolution within two weeks upon medication cessation. We report the case of a patient who presented with generalized desquamation, characteristic pustules, and several morbilliform rashes on the body surface in association with recent amoxicillin-clavulanic acid exposure. This was associated with significant pruritus, which was the associated chief complaint. A multimodal approach to symptomatic management with topical corticosteroids, barrier ointments, oral antihistamines, and analgesics was required, in addition to the cessation of the offending medication.

Adult-Onset Immunoglobulin A Vasculitis With Renal Involvement.

A 50-year-old male presented with worsening bilateral lower extremities swelling for a month, associated with a purpuric rash over bilateral upper and lower extremities, joint pain over bilateral hands and ankles, and intermittent generalized abdominal pain. Physical examination was notable for pitting edema in bilateral lower extremities and palpable, non-blanching purpuric rashes and crusts, joint tenderness over bilateral hands/wrists/ankles, and mild generalized abdominal tenderness. Laboratory tests were remarkable for sub-nephrotic range proteinuria and microscopic hematuria. The skin biopsy revealed leukocytoclastic vasculitis. Renal biopsy showed mild mesangial expansion and immunoglobulin A (IgA)-dominant mesangial deposits. The patient was diagnosed with IgA vasculitis (IgAV) nephritis (IgAVN) and was subsequently treated with oral prednisone 80 mg daily for seven days followed by slow tapering doses, oral lisinopril 2.5 mg daily, and oral furosemide 40 mg daily. At the one-month follow-up as an outpatient, his skin rash and lower extremity swelling had resolved along with an improvement of proteinuria.

Atypical Stevens-Johnson Syndrome Associated With Mycoplasma Pneumoniae.

Mycoplasma pneumoniae primarily causes atypical pneumonia in children and young adults. 7%-8% of patients with M. pneumoniae infections may experience extra-pulmonary manifestations, including M. pneumoniae-associated Stevens-Johnson Syndrome (SJS), also known as atypical SJS. In recent literature, there have been a few reports of isolated mucositis in children with M. pneumoniae infections. Due to significant overlap with several diseases, including autoimmune disease and infections, atypical mucositis associated with M. pneumoniae is often a diagnostic challenge. In addition, due to limited cases of M. pneumoniae-associated SJS, there is no established standardized treatment guideline that has been shown to reduce hospitalization duration and/or disease progression associated with M. pneumoniae-associated SJS. We report a case of isolated mucositis in the absence of cutaneous involvement in a 10-year-old patient with an acute M. pneumoniae infection. Examination revealed erythematous ulcerations of his lips and pharynx with patchy exudates and bilateral submandibular lymphadenopathy. Laboratory investigation revealed a negative respiratory polymerase chain reaction (PCR) panel, which included M. pneumoniae. Further testing revealed a positive M. pneumoniae immunoglobulin M (IgM) titer on enzyme immunoassay. The diagnosis of atypical SJS was made secondary to M. pneumoniae. Treatment was initiated with systemic steroids and oral antibiotics. Limitations in diagnostic testing for M. pneumoniae in combination with non-specific clinical presentation make for challenges in confirming this pattern of SJS due to a primary M. pneumoniae infection. In this case, serological testing confirmed our suspected diagnosis, which guided treatment and helped reveal some of the difficulties in diagnosing and managing M. pneumoniae-associated SJS.

Severe Trichotillomania: An Unusual Trigger of Recurrent Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that is most often seen in patients with type 1 diabetes mellitus. Current DKA management focuses on rapid treatment to prevent acute complications, educational intervention, and early discharge. However, patients with mental health conditions face additional barriers to establishing control over their diabetes and may be hospitalized often for DKA recurrence. Understanding a patient's mental health and intervening where necessary may be a crucial step in the effective treatment of DKA. We present a case of recurrent DKA in a young male who suffered from severe trichotillomania. Trichotillomania is a mental health disorder in which an individual has the compulsion to pull on hair because it feels good. By doing so, the skin barrier is compromised. This can lead to disfiguring lesions that can be very distressing for the individual; however, they report an inability to control the compulsion to stop pulling their hair. In our case, the patient disrupted the skin barrier, leading to increased susceptibility for recurrent infection and DKA.

Atypical primary varicella rash: Systematic literature review.

AIM: In previously healthy subjects, primary varicella presents with a distinctive vesicular rash that is more intense on the trunk and head than on the extremities. However, an atypical presentation may occasionally develop. We aimed at systematically assessing the characteristics of cases affected by atypical primary varicella rash. METHODS: The United States National Library of Medicine, Excerpta Medica and Web of Science databases were reviewed, without date or language restrictions. Articles were eligible if reporting previously healthy and immunocompetent subjects with a primary varicella rash (i.e., a photo-localised primary varicella or skin inflammation-associated primary varicella). RESULTS: Thirty-eight reports providing information on 59 cases of atypical primary varicella were identified. Twenty-four cases (median 8.5 years of age, 19 females) were photo-localised and 35 (median 4.8 years of age, 15 females) were associated with pre-existing skin inflammation (including cast occlusion, diaper irritation, operative sites, burns, insect bites, vaccinations or pre-existing skin disease). The skin rash was monomorphic and without a "starry sky" appearance. CONCLUSION: Primary varicella may have a modified presentation in areas of irritation such as sun exposure or pre-existing inflammation. There is a need for a wider awareness of these modulators of varicella rash.

Leukemia Cutis As the Initial Manifestation of Chronic Lymphocytic Leukemia Progression.

Chronic lymphocytic leukemia (CLL) is a malignant proliferation of monoclonal mature B-cells in peripheral blood. Leukemia cells can commonly spread from the blood to other sites such as the lymph nodes, liver, and spleen. However, contrary to T-cell lymphomas that can involve the skin, CLL metastasis to the skin is unusual and is rarely the first manifestation of systemic disease. When leukemia cells invade the skin, it is termed leukemia cutis. Furthermore, multiple skin morphologies can be present in leukemia cutis making diagnosis challenging. Likewise, it can be mistaken for other common etiologies such as drug or substance allergy, infection, and scabies, among others. We herein present a case of CLL with leukemia cutis as the initial manifestation of systemic disease. The initial punch biopsy results were non-specific for inflammatory changes, but a subsequent biopsy revealed findings confirming leukemia cutis. This case not only demonstrates that identifying malignant skin manifestations in a timely manner and treating them is essential, as it improves the quality of life and survival, but also demonstrates that leukemia cutis can be a dynamic disease where multiple biopsies may be needed to confirm the diagnosis, as histopathology can change over time.

Síndrome Baboon-like asociado a Parvovirus B19: A propósito de un caso en edad pediátrica / Baboon-like syndrome induced by Parvovirus B19: report of a pediatric case

Resumen El Parvovirus B19 constituye un agente viral frecuente como causa de exantemas en edad pediátrica. Responsable clásicamente del eritema infeccioso, en los últimos años se lo asoció también a erupciones cutáneas atípicas. Recientemente se ha descrito una forma de exantema periflexural asociado a distintos agentes virales, conocido como síndrome Baboon-like. Presentamos el caso de una niña de 9 años con evidencia serológica de infección aguda por Parvovirus 19 que desarrolló una erupción máculo-pápulo-petequial con lesiones acentuadas en grandes pliegues. Se realiza búsqueda de la literatura disponible en relación a los exantemas inusuales por Parvovirus y se describe el caso como síndrome simil Baboon, una manifestación cutánea de esta infección viral.

Abstract Parvovirus B19 is a common viral cause of exanthem in pediatric patients. Classically responsible for infectious erythema, in the last few years it has also been associated with atypical rashes. A form of periflexural eruption associated with viral agents has been recently described as Baboon-like syndrome. We present the case of a 9-years-old girl with serological evidence of acute Parvovirus B19 infection that developed a maculopapular-petechial rash with lesions in large folds. A review of the available literature in relation to unusual Parvovirus exanthem is performed and the case is described as Baboon - like syndrome, a cutaneous manifestation of this viral infection.

Abdominal Pain as the Manifestation of Chylomicronemia Syndrome During Pregnancy: A Challenging Diagnosis.

Hypertriglyceridemia is a frequent cause of acute pancreatitis. Levels higher than 1000 mg/dL are often associated with a genetic predisposition that can be aggravated by other factors such as pregnancy and poorly controlled diabetes. The authors report a 19-year-old primigravida that presented with abdominal pain, emesis and a pruritic rash, along with severely increased plasma triglyceride levels. Therapeutic plasmapheresis was proposed in the setting of a presumed acute pancreatitis. Chylomicronemia syndrome is a rare and frequently misdiagnosed pathology that can evolve with abdominal pain, vomiting and a specific cutaneous rash designated as eruptive xanthomatosis. This case report illustrates the challenges of achieving a correct diagnosis for rare conditions and corroborates the safety of plasmapheresis during pregnancy.

Erythema Ab Igne: A Rare Presentation of Toasted Skin Syndrome With the Use of a Space Heater.

Erythema ab igne, also known as toasted skin syndrome, is an acquired asymmetric hyperpigmented dermatosis that is caused by repeated exposure to moderate heat or infrared radiation. Hyperpigmentation is caused by the degeneration of elastic fibers and basal cells resulting in the release of melanin. Historically found in bakers and industrial workers, this condition has recently resurfaced in medical literature with the use of novel heat sources such as laptops and heated car seats. While this condition can resolve spontaneously after removal of heat exposure, delay in diagnosis and persistent exposure can lead to permanent pigmentation or progression to Merkel cell carcinoma, basal cell carcinoma, and squamous cell carcinoma.

'Shawl Sign' as a Paraneoplastic Dermatosis.

Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin lesions. It is often a paraneoplastic manifestation of internal malignancy. Hence, early recognition of this disorder is important. Although not all dermatomyositis are associated with malignancies, the ones with such association regress with the treatment of associated malignancy. In clinical practice, symptoms of muscle weakness can be vague, and skin lesions can be dismissed as sunburn. We present a case of an elder adult female who presented with dermatomyositis as a paraneoplastic syndrome secondary to an underlying Mullerian malignancy.