The Diagnosis of Common Variable Immunodeficiency After Multisystem Dysfunction.

Common variable immunodeficiency (CVID) is a primary immunodeficiency caused by the lack of B cell differentiation into plasma cells, thereby leading to decreased serum immunoglobulins. Patients with this condition are predisposed to recurrent infections and are more likely to develop certain cancers and autoimmune diseases. We report the case of a 53-year-old female suffering from recurrent pulmonary infections and a history of non-Hodgkin lymphoma (NHL) who had a poor response to the measles, mumps, and rubella (MMR) and varicella vaccines as a child, and was infected with coronavirus disease 2019 (COVID-19) twice in 2020. Testing of her antibody titers in order to determine suitability for Streptococcus pneumoniae (S. pneumoniae) vaccination found an overall decrease in major immunoglobulin classes (IgG, IgM, and IgA) and B cells with normal morphology. The diagnosis of CVID was made, and prompt treatment with intravenous immunoglobulins (IVIG) brought her IgG levels up from 282 to 680 mg/dL within three months. This case highlights the importance for providers to keep immunological dysfunction on their differentials for patients with atypical presentations involving multiple organ systems.

Cutaneous Manifestation of Diabetes Mellitus in an Unsheltered Male Leading to Emergent Hospitalization.

Diabetes mellitus (DM) is one of the most common chronic diseases in the United States. It is characterized by increased patient morbidity and mortality due to the many complications that can arise. Certain dermatological findings can be indicative of poorly controlled DM and can be a useful clue to further management. Persons experiencing homelessness (PEH) with DM often have higher rates of diabetic complications than the general diabetic population. Medical providers caring for PEH in the setting of limited resources should carefully evaluate cutaneous disease as a potential indicator of underlying illness. This physical manifestation of illness can serve to guide the next appropriate steps in management. A 41-year-old unsheltered male with an extensive medical history of hypertension, seizures, chronic diarrhea, and cocaine use was seen at a "foot-washing" medical outreach event. He presented with fevers, chills, and multiple painless right lower extremity ulcerated lesions of unspecified origin. A finger-stick glucose measurement was found to be 650 mg/dL. After immediate administration of 10 units of insulin, he was transported immediately to the emergency department and admitted. His month-long hospital course was complicated and involved the amputation of multiple toes. Preemptive outreach and management could have prevented the marked deterioration of his disease and represents the importance of outreach and regular follow-up with the PEH community.

Combined Pulmonary Fibrosis and Emphysema and Digital Clubbing.

Combined pulmonary fibrosis and emphysema (CPFE) is an underrecognized syndrome that involves simultaneous restrictive-obstructive lung disease. The prognosis is poor, and it frequently occurs with comorbidities. Heavy or former smoking is a major risk factor, and computed tomography (CT) typically shows lower zone fibrosis and upper zone emphysema. Chronic respiratory failure, pulmonary hypertension, and lung carcinoma are major causes of mortality. Diagnosis of CPFE should be combined with palliative care due to the high mortality of the condition, especially in the case of delayed diagnosis. We present the case of a 73-year-old male with a history of non-small cell lung cancer, 50 pack-year smoking, and cervical spine injury (CSI) with a late diagnosis of CPFE. After presenting to the emergency department for an acute exacerbation of dyspnea and hypoxia, he was initially treated with a congestive heart failure protocol. Further examination showed mixed pulmonary function tests as well as digital clubbing, and a CT scan showed changes indicative of advanced bullous emphysema diffusely throughout both lungs with an upper lobe predominance and basilar fibrosis. He was diagnosed with CPFE and immediately treated for both restrictive and obstructive lung diseases with supplemental oxygen, albuterol, ipratropium, corticosteroids, systemic antibiotics, as well as provided with palliative consultation. His previous history and CSI delayed diagnosis, as his lung restriction was likely assumed to be from impaired chest wall mobility rather than CPFE. This case highlights the presentation of a relatively rare disease that was confounded by comorbidities.

Resource-Limited Management of Presumptive Pyoderma Gangrenosum in an Unsheltered Patient.

Pyoderma gangrenosum (PG) is an ulcerating dermatosis associated with various chronic medical conditions. Its exact etiology is unknown but likely a function of inflammation and immune dysregulation. Treatment of PG generally follows a stepwise approach which involves extensive testing, biopsies, and potentially systemic therapy. However, patients with presumptive PG in an unsheltered homeless (USH) environment require a different approach, especially in a resource-limited setting. Our 65-year-old USH patient with an extensive medical history presented with an initial, irregular salmon-colored plaque measuring approximately 10 cm × 6 cm that eventually ulcerated with pain and purulent discharge. The consistent and judicious management of his wound in terms of gentle irrigation and appropriate dressing was performed over the course of seven months starting in April 2021. In November 2021, his wound margins shrunk by roughly 1 cm circumferentially, and the ulcer had scant serosanguinous discharge, a noticeable improvement from baseline. The previously impaired wound healing may have been due to pathergy, which was indirectly addressed by protective wound dressings. Management of chronic wounds and ulcers in patients otherwise lacking access to reliable care should avoid systemic immunosuppressants due to the inherently high-risk conditions on unsheltered streets.

Gold Dental Implant-Induced Oral Lichen Planus.

Lichen planus is a chronic inflammatory cutaneous and mucosal disease mostly affecting middle-aged individuals. The etiology of lichen planus is unknown, but current literature suggests that it is an altered immune response characterized by dysregulated T-cell activation and subsequent inflammation which can be associated with conditions like allergic contact dermatitis and hepatitis C. Additionally, heavy metals like lead, tin, arsenic, and bismuth can create inflammatory and allergic reactions that can predispose to the formation of lichen planus. This report examines the case of a 64-year-old female with longstanding oral lichenoid lesions with superimposed Wickham's striae, allergic skin reactions to several medications, and a history of receiving gold-containing dental implants. As a result of her history and subsequent allergy testing, she was found to have a gold allergy. The constant mucosal irritation from her dental implants likely was associated with the development of her oral lesions, which were confirmed to be oral lichen planus. She was recommended to apply triamcinolone 0.1% ointment to her oral lesions and to follow up with her dentist for evaluation of her filings. Further, it was recommended she replaces the dental crowns with compounds lacking gold to decrease the persistent irritation. This case represents the first such instance of gold dental fillings directly having an appreciable role in the development of oral lichen planus.

Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review.

Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.

Latent Strongyloides stercoralis in an Asymptomatic Male With Chronic Peripheral Eosinophilia.

Peripheral eosinophilia is a potentially concerning finding that can occur due to a multitude of causes. One such cause is latent helminth infections such as Strongyloides stercoralis. These parasites have broad distributions throughout the developing world, particularly South and Southeast Asia and it is estimated that roughly 200 million people have latent infections. We present the case of a 74-year-old patient from India who had asymptomatic eosinophilia since before 2006. He previously underwent an extensive workup which included testing for neoplasms, gene mutations, and lymphoproliferative disorders. After carefully examining the patient's travel history and demographic information, a parasite panel was administered which was positive for Strongyloides, thereby establishing a cause for his condition after years of expensive testing. Latent Strongyloides infections can lead to fatal dissemination if the host becomes immunocompromised. It is therefore essential to keep a detailed history of patient travel, occupation, and functional status when assessing peripheral eosinophilia so that obvious causes are not overlooked.