FULLTEXTARTICLE

ClinicalPearlsinDermatology
LisaA.DrageMD,JohnB.BundrickMDandScottC.LitinMD
MayoClinicProceedings,20120701,Volume87,Issue7,Pages695699,Copyright2012MayoFoundationforMedicalEducationand
Research

Atthe2001AnnualConferenceoftheAmericanCollegeofPhysicians,anewteachingformattoaid
physicianlearning,ClinicalPearls,wasintroduced.ClinicalPearlsisdesignedwiththe3qualitiesof
physicianlearnersinmind.First,wephysiciansenjoylearningfromcases.Second,welikeconcise,
practicalpointsthatwecanuseinourpractice.Finally,wetakepleasureinproblemsolving.

IntheClinicalPearlsformat,speakerspresentanumberofshortcasesintheirspecialtytoageneral
internalmedicineaudience.Eachcaseisfollowedbyamultiplechoicequestionansweredlivebyattendees
usinganaudienceresponsesystem.Theanswerdistributionisshowntoattendees.Thecorrectansweris
thendisplayedandthespeakerdiscussesteachingpoints,clarifyingwhyoneanswerismostappropriate.
EachcasepresentationendswithaClinicalPearl,definedasapracticalteachingpointthatissupportedby
theliteraturebutgenerallynotwellknowntomostinternists.

ClinicalPearlsiscurrentlyoneofthemostpopularsessionsattheAmericanCollegeofPhysiciansmeeting.
Asaservicetoitsreaders,MayoClinicProceedingshasinvitedaselectednumberoftheseClinicalPearl
presentationstobepublishedinourConciseReviewsforClinicianssection.ClinicalPearlsinDermatology
isoneofthem.

Case1
A32yearoldmanpresentswithrecurrentepisodesofrash(Figure1(fig1)).Theselesionsoccurina
symmetricdistributionandareasymptomatic.Theyresolvewithin2weeksofonset,andthepatienthas
had4outbreaksduringthepastyear.Heisotherwisehealthyandtakesnomedications.Headmitstoan
episodeofunprotectedsexinhishottub.Hishobbiesincludecollectingexoticfishforhishomeaquarium
andcampingandhikinginthemountains.
FIGURE1
Recurrentrashinanotherwisehealthy32yearoldman.

Question
Whichoneofthefollowingisthemostlikelyinfectiousassociation?

aPseudomonas

bHerpessimplexvirus(HSV)

cTreponemapallidum

dBorreliaburgdorferi

eMycobacteriummarinum

Discussion
Erythemamultiformepresentswithtargetoririslesionsthatareoftenlocatedonthepalmsandsoles,but
generalizederuptionsalsooccur.Althoughdrugs(sulfonamides,barbiturates,andanticonvulsants)and
infections(HSV,mycoplasmapneumonia)arecommonlyassociatedwithdevelopmentoferythema
multiforme,recurrentlesionsaremostoftenlinkedtoanHSVinfection.WhiletheskinsignsofactiveHSV
maybeapparent,insomecasestheHSVreactivationmaybesubclinical.Discontinuationofuseofany
culpritdrugsandatrialofacyclovirorotherappropriateantiviralagentforatleast6monthswouldbe
reasonableincasesofrecurrenterythemamultiforme.1

ClinicalPearl
RecurrenterythemamultiformecanbeaskinsignofHSVinfection.

Case2
An18yearoldmalefreshmanattheUniversityofColoradopresentstoyoururgentcareclinicwithfever,
malaise,headache,andrash(Figure2(fig2)).Previouslyhealthy,heistakingnomedicationsandhashad
allofhisimmunizations,includingtheprimaryandboostertetravalentvaccinesformeningococcus.
FIGURE2
Petechialrashonlowerextremityofan18yearoldmanpresentingwithfever,headache,andmalaise.

Onphysicalexamination,histemperatureis39.2C,bloodpressureis116/78mmHg,andheartrateis120
beats/min.Hisneurologicexaminationshowsnoevidenceofanyfocalabnormality.Hehasapetechialrash
onhislowerextremitiesthatprogressesoverthecourseof4hoursintheurgentcareclinic.Laboratory
testingrevealsleukocytosis(whitebloodcellcountof13.9109/L)withleftshiftedmaturation.Allother
laboratorytestresultsarepending.

Question
Inviewofthispatient'ssymptomsandexaminationfindings,whichoneofthefollowingisthemostlikely
diagnosis?

aMeningococcemia

bPrimaryrashofhumanimmunodeficiencyvirus

cRockyMountainspottedfever

dStreptococcaltoxicshocksyndrome

eAcutemeaslesinfection

Discussion
ThispatientpresentswiththeclassicrashofmeningococcemiacausedbyNeisseriameningitidis.Although
mostcommonlyseeninchildren,casesoftenoccurinpeople18yearsofageorolder.Epidemicsareseenin
crowdedsettingssuchascollegedormitories.Itisaseasonaldisease,andmostcasesareseeninwinterand
spring.Themortalityis10%to20%,withsomedeathsoccurringduetotreatmentdelay.

Patientspresentwithfever,headache,nausea,vomiting,andmyalgia.Mentalstatuschangesandnuchal
rigidityaresignsofmeningitis.Therashisacommonandearlysignandclassicallypresentswithpetechiae
scatteredonthetrunkandextremitiesthatevolverapidlytopurpurawithgunmetalgraycenters.Therapid
progressionofsignsandsymptomsisahallmarkofthisdisease.Treatmentshouldnotbedelayedfor
transfertoanotherfacility.
Atetravalentconjugatevaccine(thatcoversmeningococcalserogroupsA,C,W135,andY)wasreleasedin
theUnitedStatesin2005andiscurrentlyrecommendedforroutinevaccinationofadolescents,preferably
atage11or12,withaboosterdoseatage16.2 3Currently,therearenovaccinesavailableintheUnited
StatesforpreventionofserogroupBNmeningitidisdisease(whichisresponsibleforaboutathirdofall
cases).

ClinicalPearl
Thepetechialrashofmeningococcaldiseasehasacharacteristicappearance,progressesrapidly,andisan
earlysignofthisdisease.Thecurrentvaccinedoesnotcoverallstrains.

Case3
An18yearoldmanoriginallypresentedtoyoururgentcareclinic4weeksagowithasmallabscessonhis
knee.Hewasotherwisehealthyandtakingnomedications.Theabscesswasincisedanddrainedatthe
clinic,andthecultureandsusceptibilitystudiesshowedthislesiontobeamethicillinresistant
Staphylococcusaureusinfection.Henowpresentswithanewabscess(Figure3(fig3)).

FIGURE3
Abscessonupperextremityofan18yearoldmanwhopresentedpreviouslywithanabscessonhisknee.

Onphysicalexamination,histemperatureis37C,bloodpressureis118/76mmHg,andheartrateis80
beats/min.Skinexaminationshowsa22cmerythematousplaqueontheforearmwithacentralfluctuant
area.Thereareareasofhealingskinontheknee.

Question
Afterincisionanddrainageofthecurrentabscess,whichoneofthefollowingisthemostimportant
interventiontopreventrecurrenceofinfectionsinthispatient?
 aEducationonwoundcareandpersonalhygiene

bOralrifampin

cIntravenousvancomycin

dOralclindamycin

eCombinationtreatmentwithoraltrimethoprimsulfamethoxazoleandminocycline

Discussion
Thispatientpresentswiththetypicalhistoryandphysicalfindingsofaskinandsofttissueinfection(SSTI)
withcommunityassociatedmethicillinresistantSaureus(CAMRSA).InfectionscausedbyCAMRSA
usuallypresentasasolitaryabscess,cellulitis,orsofttissueinfection,oftenwithcentralnecrosis,butthere
arenospecificfindingstodifferentiateitfromamethicillinsensitivestaphylococcalinfection.Recurrence
inanindividualiscommon,asarecommunityclustersorinvolvementofmultiplehouseholdmembers.

Currently,CAMRSAisthemostcommoncauseofSSTIsencounteredinmosturbanemergency
departments.ThisstrainofMRSAhasadistinctgeneticresistanceelement(SCCmecIV)andtoxin
(PantonValentineleukocidintoxin)anddevelopsinpopulationswithclosephysicalcontact,suchas
children/youngadults,prisoners,homelesspersons,intravenousdrugusers,andpeopleinvolvedincontact
sports(football,fencing,rugby,wrestling,etc).Whileresistanttolactamantibiotics,CAMRSAisolates
oftenremainsensitivetootherantibioticssuchasclindamycin,trimethoprimsulfamethoxazole,and
minocycline.Antibioticsusceptibilitypatternsdifferthroughoutthecountry.

Theprimarytreatmentforasmall,simplecutaneousabscessisincisionanddrainageoftheabscess.
ManagementofrecurrentMRSASSTIsshouldfocusoneducationaboutappropriatewoundcareand
personalhygiene.Instructionshouldincludekeepingdrainingwoundscoveredwithclean,drybandages,
maintaininggoodpersonalhygienewithregularbathingandcleaningofhands,andavoidingreusingor
sharingpersonalitems(disposablerazors,linens,andtowels).Environmentalhygienemeasuresshould
focuscleaningeffortsonhightouchsurfacesusingcommerciallyavailablecleanersordetergents.

CliniciansshouldconsiderattemptingdecolonizationifapatientexperiencesarecurrentSSTIdespite
optimalwoundcareandhygienemeasuresorifongoingtransmissionisoccurringamonghousehold
membersdespitethesemeasures.4Decolonizationstrategiesmayincludenasaldecolonizationwith
mupirocintwiceadayfor5to10daysandbodydecolonizationwithaskinantisepticsolution
(chlorhexidine)for5to14daysordilutebleachbaths.

ClinicalPearl
PreventionofrecurrentCAMRSAshouldfocusfirstonwoundcareandpersonalhygieneeducation.

Case4
An18yearoldpatientpresentswithasorethroatandsignsofstreptococcalpharyngitis.Youstart
treatmentwithamoxicillinclavulanate,andresultsofarapidstreptestarepositive.Thenextdaythe
patientcallsregardinganewrashthathaseruptedalloverhisbody(Figure4(fig4)).Thepalmsandsoles
remainuninvolved.
FIGURE4
Eruptionofanewrashinan18yearoldmanwhopresented1daypreviouslywithasorethroatandsignsof
streptococcalpharyngitis.

Question
Whichoneofthefollowingisthemostlikelycauseofthispatient'srash?

aDrugrash

bPityriasisrosea

cStreptococcalscaldedskinsyndrome

dMycoplasmapneumonia

ePsoriasis

Discussion
Psoriasisisacommondiseasewithmanydifferentclinicalpresentations.Guttatepsoriasisclassically
presentsafterinfectionwithstreptococcusinchildrenoryoungadults.Guttatepsoriasispresentswith
scaly,droplikepapulesonthetrunkandextremities.Itisoftenmistakenforadrugrashbecause
antibioticsmayhavebeeninitiatedforthestreptococcalinfection.Throatculturesforstreptococcal
pharyngitisshouldbeobtained.Guttatepsoriasishasagoodprognosisandmaydisappearspontaneouslyor
maybenefitfromphototherapy.5
ClinicalPearl
Infectionscancauseflaresofpsoriasis.Streptococcalpharyngitisisacommoncauseofguttatepsoriasis.

Case5
A28yearoldmanpresentswitharashandpruritus(Figure5(fig5))thathasbeenpresentfor3weeks.He
hasnohistoryofskinorotherhealthproblemsandisnotreceivinganymedications.Hehasusednonew
productsontheskinandhasnotfrequentedwoodedareas.Onexamination,hehasredpapulesand
excoriationsonthewrists,groin,andaxillaeandnodularareasonhisscrotum.

FIGURE5
Rashandpruritusof3weeks'durationinanotherwisehealthy28yearoldman.

Question
Toidentifythecauseofthispatient'srashandpruritus,whichoneofthefollowingisthebestlaboratory
test?

aMineraloilpreparationofaskinscraping

bTissuetransglutaminasemeasurement

cSkinbiopsy

dLymediseaseserology

eSkinbiopsyfortissueculture

Discussion
ScabiesiscausedbyinfestationoftheepidermiswiththemiteSarcoptesscabieivar.hominis.Infection
occursasaresultofdirectskintoskincontactfomitetransmissionisuncommon.Scabiescauses
epidemicsinschools,nursinghomes,andhospitals.Pruritusisthemajorcomplaint,prominentlyatnight,
andthereisoftenahistoryofitchingorrashinfamilymembersandclosepersonalcontacts.Therashis
duetohypersensitivityreactiontothemiteprotein.

Clinicalfeaturesincludeinflammatory,excoriatedpapulesinthewebspacesofthehandsandfeet,the
axillae,groin,wrists,andareolae,andsubmammarysitesinwomen.Facialorscalpinvolvementis
uncommon,exceptinchildrenandelderlypersons.Nodulesorthickenedareasinthescrotumarealsoa
helpfulclue.Thepathognomonicfindingisaburrow,commonlylocatedonthehands.Identificationof
mites,eggs,orfecalmaterialonascabiespreparationisdiagnostic.Inimmunocompromisedpatients,
scabiesmayappearasageneralizedscalingeruption(crustedscabies,formerlycalledNorwegianscabies).
Thisformofscabiesishighlyinfectiousandcancauseepidemicsinhospitalsornursinghomes.

Treatmentofclassicscabiesincludesthetopicalapplicationofpermethrin,whileoralivermectinmaybe
usedinthetreatmentofcrustedscabies.6

ClinicalPearl
Scabieshasapathognomonicdistributionandskinfinding(burrow).Isolationofthemitewithascabies
preparation(skinscraping)isthebestdiagnostictest.

Case6
A68yearoldpatientwithdiabetesmellitusandchronicrenalinsufficiencypresentsforevaluationof
hardeningoftheskinofhisneckandupperback.Hehasnoteddecreasedrangeofmotioninhisneckand
statesthatitjustfeelstight.Thesymptomshavebeenprogressing.Sixmonthsago,heunderwent
magneticresonanceimagingofhislumbarspineforpseudoclaudication.

Onphysicalexamination,hehasnoevidenceofsynovitisoranyadditionalskinfindings.Theonlynotable
findingisabrawnythickeningoftheskinoftheupperbackandneck(Figure6(fig6)).

FIGURE6
Brawnythickeningoftheskinoftheupperbackandneckina68yearoldmanwithdiabetesmellitusandchronicrenal
insufficiency.

Question
Whichoneofthefollowingisthemostlikelydiagnosisinthispatient?
 aScleroderma

bScleredema

cEosinophilicfasciitis

dNephrogenicsystemicfibrosis

eMorphea

Discussion
Scleredemaisanunderrecognizedskinsignofinternaldiseaseandisprimarilyseeninassociationwith
diabetesmellitus,paraproteinemia,andstreptococcalinfection.Itpresentswiththickeningandstiffnessof
theskinontheupperbackandposterioraspectoftheneck.Inadults,itiscommonlyseeninassociation
withdiabetesmellitus.Itmayalsobeseeninassociationwithmultiplemyeloma/paraproteinemia,
hyperparathyroidism,rheumatoidarthritis,Sjgrensyndrome,insulinoma,andhumanimmunodeficiency
virusinfection.Inchildren,itmaybeseenfollowingastreptococcalinfection.Characteristicbiopsyfindings
includeexcessivemucindepositionandmildsclerosis.

Otherskinsignsofdiabetesmellitusincludecandidainfectionsofthemouthandgenitalia,diabeticbullae,
diabeticdermopathy(brownshinspots),necrobiosislipoidica,footulcers,acanthosisnigricans,granuloma
annulare,insulinlipodystrophy,anderuptivexanthoma.7 8

ClinicalPearl
Scleredemapresentswithsymmetricskinthickeningoftheupperbackandposterioraspectoftheneckand
maybeassociatedwithdiabetesandavarietyofothermedicalconditions.

Seeendofarticleforcorrectanswerstoquestions.

CORRECTANSWERS:Case1:b.Case2:a.Case3:a.Case4:e.Case5:a.Case6:b

References
1.WetterD.A.,andDavisM.D.:Recurrenterythemamultiforme:clinicalcharacteristics,etiologic
associations,andtreatmentinaseriesof48patientsatMayoClinic,2000to2007.JAmAcad
Dermatol201062:pp.4553
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1016/j.jaad.2009.06.046)

2.UpdatedrecommendationsforuseofmeningococcalconjugatevaccinesAdvisoryCommittee
onImmunizationPractices(ACIP),2010.MMWRMorbMortalWklyRep201160:pp.7276
CrossRef(http://www.cdc.gov/mmwr/mmwrpvol.html)

3.StephensD.S.:Conqueringthemeningococcus.FEMSMicrobiolRev200731:pp.314
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1111/j.15746976.2006.00051.x)
4.LiuC.,BayerA.,CosgroveS.E.,etal:ClinicalpracticeguidelinesbytheInfectiousDiseases
SocietyofAmericaforthetreatmentofmethicillinresistant.ClinInfectDis201152:pp.e18e55
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1093/cid/ciq146)

5.NestleF.O.,KaplanD.H.,andBarkerJ.:Psoriasis.NEnglJMed2009361:pp.496509
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1056/NEJMra0804595)

6.CurrieB.J.,andMcCarthyJ.S.:Permethrinandivermectinforscabies.NEnglJMed2010362:
pp.717725
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1056/NEJMct0910329)

7.AhmedI.,andGoldsteinB.:Diabetesmellitus.ClinDermatol200624:pp.237246
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1016/j.clindermatol.2006.04.009)

8.PerezM.I.,andKohnS.R.:Cutaneousmanifestationsofdiabetesmellitus.JAmAcadDermatol
199430:pp.519531
CrossRef(http://dx.doi.org.ezproxy.qu.edu.sa/10.1016/S01909622(94)700583)

Copyright2017Elsevier,Inc.Allrightsreserved.