Acute rheumatic fever and erythema marginatum in an adult patient.

A 41-year-old woman presented for evaluation of a pruritic eruption with an abrupt onset, starting on her flanks and then spreading to her arms and legs. She had 2 weeks of fever, chills, malaise, migratory joint pain, nausea, and mental confusion. An antistreptolysin O titer was positive. Upon hospital admission, bilateral lower-extremity chorea movements were observed, and her C-reactive protein level was elevated (3.7 mg/dL). Biopsy results supported erythema marginatum. Based on these clinical and laboratory findings, the diagnosis of acute rheumatic fever was established.

Acute inflammatory edema as a variant of pseudocellulitis resolved after transcatheter aortic valve implantation.

Acute inflammatory edema is a noninfectious inflammatory condition of the skin that is commonly seen in critically ill patients. It is characterized by edematous, erythematous, and nontender plaques involving the abdomen and thighs, sparing areas of the skin subject to pressure. Risk factors include fluid overload, hypoalbuminemia, and obesity. Differentiating acute inflammatory edema from cellulitis can be challenging. Supportive care is the mainstay therapy for acute inflammatory edema, with interventions primarily focused on lowering the fluid burden. We report an unusual case of a nonobese patient in the outpatient setting with acute inflammatory edema.

Eosinophilic annular erythema.

Eosinophilic annular erythema (EAE) is a rare eosinophilic dermatosis characterized by annular, erythematous papules and plaques commonly found on the trunk and the extremities. There is continued debate on whether EAE is a distinct entity or a clinical polymorphism of Well's syndrome, but it is generally considered a separate entity based on clinical and histopathological differences. We present a case of EAE and discuss the histopathological findings.

An unusual presentation of eruptive syringomas on the neck.

Dermatologic manifestations can be the initial signs of a systemic disease, and a thorough investigation may be warranted to rule out a life-altering diagnosis. We present a case of an 11-year-old boy with a concurrent presentation of eruptive syringomas and juxtaclavicular beaded lines on his neck. While a biopsy confirmed the benign diagnosis, the initial presentation led to a concerning differential including pseudoxanthoma elasticum and warranted a complete investigation.

A painful periumbilical rash.

Jacquet's erosive dermatitis, or dermatitis syphiloides posterosiva, is classified as a severe irritant dermatitis characterized by erythematous papules and nodules with erosive, punched-out lesions. It can be found in the perineal distribution and is frequently reported in infants over 6 months of age. In adults, it is associated with urinary or fecal incontinence. We present a case of a 21-year-old white woman with a history of chronic umbilical drainage and a 3-year history of a periumbilical rash with red, friable, well-demarcated papules. Biopsy revealed pseudoepitheliomatous hyperplasia with focal epidermal erosion and a superficial perivascular infiltrate of lymphocytes and plasma cells. Our case sheds light on this uncommon diagnosis in an unlikely location.

Diagnosing an ulcerated gouty tophus.

We present the case of a 44-year-old man with a complicated past medical history who presented with presumed sepsis secondary to pneumonia and severe joint pain secondary to gout. Despite an entirely negative infectious workup during his lengthy hospitalization, he developed ulcerated, draining wounds on his hands and feet that were also initially presumed to be infectious. The chalky substance draining from the wounds was eventually evaluated with potassium hydroxide under polarized microscopy and found to have the characteristic negative birefringence of sodium urate crystals. He was treated with steroids after an infectious etiology had been ruled out, and he improved clinically once his uric acid levels began to fall.

Mohs Micrographic Surgery for the Management of Cutaneous Malignancies.

Mohs micrographic surgery is a specialized form of skin cancer surgery in which the Mohs surgeon acts as both surgeon and pathologist. The procedure is characterized by its histopathologic margin control and ability to spare tissue, particularly in cosmetically sensitive locations. Mohs surgery is known for both limiting the size of the final defect and its high cure rate. In this review, the authors highlight indications for the procedure, detail the technique itself, discuss cutaneous tumors for which Mohs micrographic surgery is indicated, and present the economic benefit of Mohs surgery.

Painful nipple hyperkeratosis secondary to vemurafenib.

Vemurafenib is a selected BRAF kinase inhibitor approved for treating metastatic or unresectable melanoma, which has numerous cutaneous side effects unfortunately, including three previously reported cases of asymptomatic areola and/or nipple hyperkeratosis. We present the first case of painful bilateral nipple hyperkeratosis secondary to vemurafenib in an 84-year-old woman. She was successfully treated with tretinoin 0.05% cream that allowed her to comfortably continue treatment. With increased awareness of this condition, we found a second case of asymptomatic nipple hyperkeratosis secondary to vemurafenib in our clinic. As this medication gains acceptance for treatment of metastatic melanoma, it is imperative that dermatologists are aware of this potentially uncomfortable side effect that can result in decreased compliance and impaired quality of life.

Dermatophytic Pseudomycetoma of the Scalp.

Dermatophytic pseudomycetoma represents a chronic infection characterized by a tumor-like growth containing dermatophytes arranged as clustered aggregates (grains) within the dermis. In contrast to mycetomas, they lack sinus tracts and are more common in the scalp. We describe a dermatophytic pseudomycetoma arising in the scalp of an 18-year-old African-American woman. Histopathologic examination showed a dense, mixed-cell infiltrate expanding the dermis. Accompanying this infiltrate were numerous grains scattered throughout the dermis. No sinus tracts were identified, but a number of grains were seen in the epidermal surface, admixed with serum crust. Recognition of a dermatophytic infection as a pseudomycetoma on a biopsy is important, as surgery may be required for a successful treatment.

Chondrodermatitis nodularis helicis: A review of current therapies.

Chondrodermatitis nodularis helicis (CNH) is characterized by a tender nodule located on the helix or antihelix. Age groups impacted by CNH vary from study to study, but the majority of studies report an average age range from 50 to 80 years. Various treatment options have been described in the literature, including surgical techniques, laser therapy, curettage, topical and intralesional corticosteroids, and pressure relieving techniques. The main goal of therapy is to reduce pain and improve clinical appearance. In recent years, new therapies have been described for CNH with great results and lower recurrence rates. It is our hope that this review can serve as a reference for both practitioners and patients looking to treat CNH.

Segmental neurofibromatosis with deep schwannoma.

An elderly patient presented with two clusters of asymptomatic fleshy and pedunculated papules. Biopsy of the papules was consistent with neurofibromas. Decades prior she had undergone a surgery for the excision of a large schwannoma. Given her lack of other neurofibromatosis findings, the patient was diagnosed with multisegmental neurofibromatosis (multi-SN) with deep schwannoma, a possible new phenotype of SN. Because this entity may be associated with internal malignancy, it is important to screen and educate these patients as well as to provide regular follow-up.

Complex regional pain syndrome.

Complex regional pain syndrome (CRPS) is a neurologic disorder that often results in debilitating chronic pain, but the diagnosis may elude providers as it is one of exclusion. A history of trauma may be elucidated. We report a case of CRPS and review the clinical findings, appropriate workup, and treatment options for the patient. The patient we describe went through an extensive workup before receiving the correct diagnosis. Delay in diagnosis leads to prolonged suffering for the patient and, at times, unnecessary invasive debridement procedures. Raising awareness of this entity may help physicians make the correct diagnosis early, as well as initiate a collaborative effort between neurology, anesthesiology, and dermatology to provide the patient the most favorable outcome.

Bevacizumab-induced pityriasis rubra pilaris-like eruption.

Pityriasis rubra pilaris is a rare inflammatory disorder characterized by follicular papules on an erythematous base often exhibiting islands of unaffected skin, follicular plugging, and palmoplantar hyperkeratosis. While vitamin A deficiency and autoimmune reactions have been hypothesized as possible etiologies of this condition, pityriasis rubra pilaris-like eruptions secondary to medications are extremely rare. To our knowledge, only three other cases have been reported, and pityriasis rubra pilaris has never been reported in association with bevacizumab. We present a 70-year-old man who developed erythroderma both clinically and histologically consistent with pityriasis rubra pilaris 10 days after intravitreal injection of bevacizumab for age-related macular degeneration. As immune-modulating drugs grow in their application for a host of diseases, recognition of associated medication complications is important.

Leprosy in a texan.

A 69-year-old man from Texas with an unremarkable past medical history presented with a 2-year history of a diffuse, spreading annular eruption involving most of his trunk. He noticed progressive numbness of his hands and feet but no other systemic symptoms. He had never traveled outside of the United States. Skin biopsy confirmed a diagnosis of leprosy, and he was initiated on appropriate therapy.

Intravenous zinc therapy for acquired zinc deficiency secondary to gastric bypass surgery: a case report.

Zinc deficiency may result from either a congenitally inherited defect of zinc absorption or is acquired secondarily from a variety of factors affecting dietary zinc intake, absorption, or loss. We report a case of acquired zinc deficiency secondary to gastric bypass surgery that resulted in vulvar cutaneous manifestations of delayed onset, with failure to clear after oral supplementation with zinc. The patient experienced improvement of symptoms only after administration of intravenous zinc supplementation. Upon review of the current literature, it is thought that the patient's original suboptimal response to oral supplementation and improvement after receiving intravenous zinc were related to the intentional surgical alteration and bypass of the absorptive capacity of the duodenum and jejunum. With the current prevalence of obesity and availability of surgical weight loss therapies, it is important to be mindful of the resulting nutritional deficiencies, their clinical manifestations, and factors affecting the efficacy of therapeutic approaches as seen in this case.

Disseminated nocardiosis in a patient on infliximab and methylprednisolone for treatment-resistant Sweet's syndrome.

A 62-year-old white man with a 10-year history of treatment-refractory Sweet's syndrome was admitted to the hospital with the onset of purpuric lesions. Methylprednisolone and infliximab were administered. Our patient developed disseminated Nocardia infection and eventually succumbed. Opportunistic infections such as Nocardia have been associated with infliximab and other tumour necrosis factor (TNF)-α inhibitors. The astute clinician should be aware of the risk of rare opportunistic infections, particularly in patients on TNF-α inhibitors and systemic corticosteroids.