Feasibility and cost of a medical student proxy-based mobile teledermatology consult service with Kisoro, Uganda, and Lake Atitlán, Guatemala.

BACKGROUND: The expansion of mobile technology and coverage has unveiled new means for delivering medical care to isolated and resource-poor communities. Teledermatology, or dermatology consultation from a distance using technology, is gaining greater acceptance among physicians and patients. OBJECTIVES: To evaluate feasibility and cost of a smartphone-based teledermatology consult service utilizing a designated medical student proxy to facilitate all consults on site, and to evaluate the service's effect upon diagnosis and management. METHODS: An IRB-approved smartphone-based teledermatology consult service was established to serve two rural communities in the developing world: Kisoro, Uganda, and Lake Atitlán, Guatemala. Fourth-year medical students were recruited as proxies for each site, responding to consults by local doctors and transmitting photographs and clinical information via a smartphone application to a dermatology resident and attending in the USA over an encrypted website. At the Ugandan site, when indicated, the medical student performed skin biopsies under supervision, and rotating Montefiore residents transported specimens back to the USA. RESULTS: From October 2011 to August 2012, 93 cases were evaluated by the consult service (57 from Uganda and 36 from Guatemala). Initial diagnoses changed completely in 55.9% (52 of 93) of cases, and management changes were recommended in 89.2% (83 of 93) of cases. The estimated total cost of supplies and technology was 42.01 USD per consult and 64.24 USD per biopsy (including processing). Given fixed upfront costs, the cost per consult decreased with each additional case. CONCLUSION: Smartphone-based systems for teledermatology consultation using a medical student proxy are feasible for delivery of care in the developing world at relatively little cost. Optimization and sustainability of this system requires and deserves further investigation in larger studies.

Multicentric reticulohistiocytosis: contrasting presentations in 2 Hispanic patients.

Multicentric reticulohistiocytosis (MR) is a rare debilitating disease that involves the skin and joints. It most commonly affects white individuals but has been reported in other ethnic groups including black individuals, Native Americans, and Asians. The Hispanic population is largely underrepresented in the epidemiology of MR. We describe 2 Hispanic patients with contrasting presentations of MR. Prompt recognition of MR is essential to expedite treatment and prevent potentially disabling sequelae of undiagnosed disease; however, diagnosis can be challenging due to the wide range of clinical presentations of MR as well as variable laboratory findings, especially in patients with skin of color. Our case reports underscore this phenomenon and demonstrate the importance of considering MR in all ethnic groups, including Hispanic patients.

Kaposiform hemangioendothelioma with Kasabach-Merritt syndrome mistaken for child abuse in a newborn.

Kaposiform hemangioendothelioma is a rare vascular neoplasm of childhood that may have an alarming and potentially misleading clinical presentation. Awareness of this entity is important to provide appropriate and immediate medical care. We report the case of a 24-day-old female newborn who presented with a large bruiselike lesion on the left leg. A diagnosis of cellulitis suspected to be secondary to child abuse was made and the patient subsequently was placed in foster care; however, the lesion did not resolve after treatment and relocation. On reevaluation at our institution, physical examination revealed a round, 3 x 4-cm, violaceous, indurated, fixed, nonblanching, nontender plaque with an ivory center and peripheral erythema over the anteromedial aspect of the left leg. Biopsy demonstrated a vascular neoplasm consistent with kaposiform hemangioendothelioma (KHE), and laboratory evaluation revealed thrombocytopenia, low fibrinogen levels, and elevated D-dimer levels, confirming a diagnosis of Kasabach-Merritt syndrome (KMS).

Merkel cell carcinoma arising in a patient with a history of multiple malignancies.

Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine carcinoma of the skin. Although the association between MCC and other primary malignancies has been documented, the mechanism of this association has not been elucidated. We report a case of MCC in a man with a history of multiple primary malignancies and treatment with immunomodulators. This case highlights the increased incidence of other malignancies in patients with MCC and is unique given the number and diversity of primary malignancies found in this patient.