A 14 year old girl is admitted to the Infectious Disease unit with fever, a dry cough, red eyes, crusted lips and a skin rash which affects her palms, soles and extensor surfaces of arms and legs. She felt increasingly unwell for 3 days prior to admission with lethargy and myalgia.  She is finding it very painful to eat and drink.

She is usually fit and well and is on no regular medication.  The only medication she has taken is paracetemol, and she’s not sure whether the rash was present before she took this.

She lives in the UK and last visited her maternal relatives in Bangladesh 5 years ago.

On examination:

Temp: 37.6     BP: 117/60          Pulse: 88              Oxygen sats: 92% on air                RR: 18

General examination: Looks miserable and generally unwell.  Erythema of the skin around both eyes, with bilateral conjunctival injection.  Haemmorhagic crusting of upper and lower vermillion lips (patient declined permission to use photographs of her face).  Shallow ulceration of buccal and palatal mucosae.

Examination of chest and abdomen reveals no obvious abnormality.

• Can you describe the rash?
• What diagnoses would you consider at this point, and which is most likely?
• What further tests would you order?

Many thanks to Dr Ann Sergeant, Dermatology Consultant, for our first case of 2013.

Students, let us know what you think on the class discussion boards.

A 40 year old night club doorman presents with fragile skin on the dorsum of both hands.  He’d been in a fight and thought they’d been slow to heal, but recently he’s noticed some blisters on his hands and erosions on his forehead too.

He has a history of chronic knee pain and previous depression.  His current medications are cocodamol 30/500 qid, naproxen 500mg bd and occasional gaviscon. He smokes 20 cigarettes per day and admits to drinking 8 pints lager/day.  He works out regularly in the gym and uses sunbeds twice a week.  He sometimes uses cocaine, ecstasy or one of the newer ‘legal’ highs.  He no longer uses IV drugs and says tests for hepatitis and HIV 2 years ago were negative.

On examination he is well built with a dark tan.  He has some hyperpigmentation on the dorsum of his hands, along with eroded areas and some milia.  There are no frank bullae.  His forehead has a couple of erosions and some hyperpigmentation.  The rest of his physical exam is essentially normal. MSc students, have a look at the picture of the rash in the classroom.

• What are the possible diagnoses you would consider?
• What tests would you do?

Many thanks to Dr Ann Sergeant for this case. Dr Sergeant will be moderating the discussion this week.

A 70 year old lady presents with a 3 week history of an itchy rash.  She feels systemically well.  She has a history of osteoporosis, depression and suspected fungal toe nail infection for which she has been taking terbinafine 250mg daily for the last 8 weeks. Her general practitioner has prescribed fexofenadine 180mg daily without much benefit.

The rash is shown here, along with a close-up.

• Describe the distribution and morphology of the rash.
• What is your differential diagnosis?

More info and questions later in the week for our MSc students.

Many thanks to Dr Ann Sergeant for this case.

                     Rash in 2005                                  Rash Now

A 93 year old woman is referred with a 7 day history of painful bullae on her chest wall and back.  She was diagnosed with a blistering rash in 2005 and required treatment with oral corticosteroids for 1 year.  She has been off all treatment for her skin since then.  Her general practitioner restarted her prednisolone at a dose of 30mg daily 3 days ago, but there has been no improvement in her skin.  She is otherwise remarkably well.  She is on regular aspirin 75mg od and vitamin D/calcium supplements.