(BMJ)—An otherwise healthy 3-mo boy born full-term by normal vaginal delivery had progressive hair loss in a band across his occiput x1mo. Exam: positive hair pull test. Trichoscopy: reduced hair density, preserved follicular ostia, and telogen hairs. What is the dx?
Halo scalp ring
Cephalohematoma
Nevus sebaceus of Jadassohn
Neonatal occipital alopecia
Pressure alopecia
You are correct. Neonatal occipital alopecia (NOA) was confirmed when the child had complete reversal of alopecia w/o any specific tx. NOA is a localized, nonscarring, physiological alopecia, representing the synchronized shedding of telogen hairs initiated in utero. It is assoc w/ factors such as nonelderly gravida and delivery not done by C-section, but it is not assoc w/ sleeping position. Reassure parents about the self-limiting nature of NOA and inform them that the infant’s sleeping position is not related to NOA, as changing the position from supine to prone may lead to SIDS.

Archives of Disease in Childhood Published Online First: 14 March 2018. doi: 10.1136/archdischild-2018-314825
(BMJ)—A 51-yo woman w/ prior L eye trauma and fungal infection presented w/ L eye pain, light sensitivity, and inability to close the eyelid. In the L eye, her best corrected visual acuity was reduced to hand motion; in the R eye, visual acuity was 20/40. Intraocular pressure: WNL. L eye: severe conjunctival injection, protruding blue lesion w/ iridocorneal adhesions. What is the dx?
Uveal melanoma
Acquired anterior staphyloma
Scleromalacia
Buphthalmos
Coloboma
You are correct. Acquired total anterior staphyloma is a rare anterior segment pathology w/ protrusion of uveal tissue through a defect in the cornea or sclera, due to trauma, corneal ulcers, or vitamin A deficiency or congenitally as a component of Peters anomaly. It is typically seen in low- and middle-income countries due to lack of posttrauma f/u care, in infectious keratitis, or because of poor compliance to tx. This pt did well, and her best corrected visual acuity improved to 20/100 after aphakic correction and corneal graft placement.

BMJ Case Reports 2018; doi:10.1136/bcr-2018-224271
(BMJ)—A 12-yo boy presented w/ progressive darkening of fingernails and toenails x3mo. There was no hx of exposure to dyes and no trauma. Exam: blue-black nails w/ hyperpigmented nail beds and distal phalanges. Labs: Hgb, 10.9 g/dL. Adrenocorticotropic hormone level WNL. What is the dx?
HIV infection
Iron deficiency
Wilson dz
Onychomycosis
Vitamin B12 deficiency
You are correct. A serum vitamin B12 level confirmed the dx. Nail changes in vitamin B12 deficiency are less common than typical clinical manifestations such as anemia, glossitis, and neurological sx. Nail changes include hyperpigmentation, bluish discoloration, blue-black pigmentation w/ dark longitudinal streaks, and longitudinal and reticulate darkened streaks. The nail pigmentation assoc w/ vitamin B12 deficiency is more frequent in dark-skinned pts. This pt was treated w/ oral and IM vitamin B12.

BMJ Case Reports 2018; doi:10.1136/bcr-2018-224258
(Epocrates)—A 35-yo female w/ no significant PMHx reported constant numbness and tingling in the 1st and 2nd digits of her R foot after spending 3 days at a rodeo. She experienced no pain or radiation, and her ROM was normal. She admitted to having “a few drinks” of alcohol but had no hx of illicit drug use. Her physical exam was unremarkable, and routine lab tests were all negative. What is the dx?
Herniated disc
Diabetic neuropathy
Compression neuropathy
Alcohol-induced palsy
Fibromyalgia
You are correct. Entrapment neuropathy, also known as compression neuropathy, of the lower limb is a challenging dx often made based on MRI studies, knowledge of neural anatomy, clinical syndromes, and denervation patterns.1 External compression from ill-fitting shoes, such as cowboy boots, is a common etiology in foot paresthesias, making a detailed hx of footwear an important clinical tool in this dx.2

References

1. Bencardino JT, Delaney H. Entrapment neuropathies of the lower extremity. In: Hodler J, von Schulthess GK, Zollikofer C, eds. Musculoskeletal Diseases 2013–2016: Diagnostic Imaging and Interventional Techniques. Springer, Milano; 2013:181-193.

2. Tandon PN, Ramamurthi R. Ramamurthi & Tandon’s Textbook of Neurosurgery. 3rd ed. New Delhi, Delhi: Jaypee Brothers Medical Publishers Ltd.; 2012.
[Source: Epocrates PDF]
(BMJ)—A 41-yo man presented w/ a 6-day hx of unilateral L eye pain after a caterpillar fell into his eye while he was on an adventure vacation. He had initially sought medical attention in the U.S., where multiple foreign bodies were seen on exam, and he was treated w/ chloramphenicol eye ointment. On re-presentation in the U.K.: visual acuity, 20/20. Eye exam: Optic disc and macula normal. Multiple setae (fibers from caterpillar) noted in conjunctiva and eyelids. Multiple corneal abrasions. What is the dx?
Phlyctenular keratoconjunctivitis
Chloramphenicol-related allergic keratoconjunctivitis
Pinguecula
Ophthalmia nodosa
Ocular leishmaniasis
You are correct. Ophthalmia nodosa is an ocular inflammatory reaction due to setae from caterpillars, spiders, or vegetation entering the eye. Microscopic barbs on the surface of setae facilitate their entry into the cornea, w/ subsequent migration to underlying structures, leading to potentially sight-threatening conditions such as vitritis and endophthalmitis. Tx requires scrupulous removal of setae. Long-term f/u is recommended due to late presentation of retained migrating setae. This pt required multiple visits for setae removal.

BMJ Case Reports 2018; doi:10.1136/bcr-2018-224194