(BMJ)—A 59-yo man presented w/ a painful rash on his face, neck, and extremities, w/ associated fever. The rash followed a URI 1wk before. He was treated w/ valacyclovir, w/o improvement. Exam: extensive papules and plaques w/ mamillated surface and a pseudovesicle quality. Labs: WBC normal, 77% neutrophils. Erythrocyte sedimentation rate elevated. What is the dx?
Tuberculosis
Sweet syndrome
Halogenoderma
Sporotrichosis
Erythema nodosum
You are correct. Sweet syndrome, also called acute febrile neutrophilic dermatosis, is a rare reactive dermatosis, which can be triggered by infxn, meds (eg, granulocyte-colony stimulating factor), systemic dz (eg, IBD), or malignancy (esp hematological). This pt achieved remission after tx w/ steroids and thalidomide.

BMJ 2018;360:k1189
(BMJ)—A 3-wk-old boy, born full term w/o complications by normal vaginal delivery and exclusively bottle fed, presented w/ oral ulcerations on the hard palate x1wk. The infant did not respond to miconazole and was refusing to feed. Exam: dehydrated, restless. Labs: WNL. What is the dx?
Candida
Epstein pearl
Bednar aphthae
Herpes simplex
Coxsackievirus
You are correct. Bednar aphthae was diagnosed clinically. It is caused by repeated trauma due to nonorthodontic nipples and pacifiers, a horizontal feeding position, and narrow nipple holes, which require vigorous sucking. An immunological process may be involved because the lesions are localized near lymphoid tissue and occur predominantly in term neonates who are spontaneously born (exposed to vaginal flora). In this pt, analgesia and change to feeding bottles w/ orthodontic nipples led to rapid improvement, and lesions completely resolved w/o scarring w/in 2mo.

Archives of Disease in Childhood Published Online First: 08 December 2017. doi: 10.1136/archdischild-2017-314045
(BMJ)—A previously healthy 7-yo girl presented w/ a facial rash that began 3mo prior on her L eyelid, as a small red plaque. She was treated w/ increasingly more potent steroids, but the rash grew. Exam: 10-cm annular plaque w/ red, scaly borders in a concentric ring pattern around L eye. What is the dx?
Erythema annulare centrifugum
Erythema gyratum
Tinea incognito
Discoid lupus erythematosus
Granuloma faciale
You are correct. Tinea incognito was confirmed by cx of skin scrapings. It is a fungal skin infxn w/ altered clinical features due to prolonged use of immunosuppressive agents. Fungal antigens trigger host immune responses, leading to the clinical manifestations of local erythema and scaling. However, concomitant steroids dampen the local inflammatory response, modifying the clinical presentation of dermatophytosis. Suspect tinea incognito in a pt w/ a progressive rash after steroid use. This pt was successfully treated w/ antifungal terbinafine cream.

Archives of Disease in Childhood 2018;103:13.
By vgreene, 2 July, 2018

RBT

(BMJ)—A 25-yo woman presented w/ progressive vulvar swelling and low-grade fever x2y, w/ recent onset of redness, dragging pain, and difficulty walking. Exam: nonulcerative, hard, bosselated bilateral vulvar swelling; raised local temperature; palpable inguinal nodes. Mantoux test was negative. Erythrocyte sedimentation rate = 60. Pelvic U/S normal. What is the dx?
Tuberculosis
Metastatic Crohn dz
Donovanosis
Filariasis
Paget dz
You are correct. Vulvar elephantiasis is a rare presentation of filariasis caused by Wuchereria bancrofti and Brugia malai in endemic areas. Microfilariae reside in the lymphatic system and lead to lymphedema. The worm is usually not found in peripheral blood or w/in the involved tissue. Dx is based on clinical suspicion, w/ elevated eosinophils, positive filarial antigen assay, and r/o of other possible causes, w/ bx or other tests. This pt was treated w/ diethylcarbamazine (DEC) and advised to wear tight undergarments and maintain local hygiene to prevent secondary infection. Cosmetic surgery was advised after completing the course of DEC.

BMJ Case Reports 2018; doi:10.1136/bcr-2018-224250