Log in Sign up
Cart

SAEM Clinical Image Series: The Insidious Rash

Posted by Monica Mitta on

A 60-year-old African American female with a history of hypertension presents to the emergency department for an itchy, diffuse rash. She first noticed the lesions a few years prior, and they have progressively become larger and more inflamed. The lesions have become severely pruritic over the last couple of months. Steroid creams did not appear to improve symptoms. Currently, the lesions on her arm have become painful with yellow drainage. The patient denies nausea, vomiting, and fever.

Additional Images

Physical Exam

Vitals: Blood pressure 182/90; pulse 100; respiration rate 11; temperature 36.2°C

Constitutional: Alert and oriented, well-nourished, no acute distress

Cardiovascular: Regular rate and rythm

Pulmonary: Lungs clear to auscultation bilaterally

Neck: Supple, no masses or lymphadenopathy

Musculoskeletal: Normal range of motion and strength, no tenderness or swelling

Skin:

  • There is diffuse involvement of skin with hypopigmented, dry scaly patches and plaques.
  • There is an area of induration in the left axilla measuring 4 x 2 centimeters with purulent discharge.
  • Posteriorly, on the buttock, the patient has three focal areas of skin breakdown, consistent with pressure ulcer.

The remainder of the exam is unremarkable.

Labs

Complete blood count (CBC) and comprehensive metabolic panel (CMP) were unremarkable.

Case Question: What is the differential diagnosis for this patient’s rash?

  • Psoriasis
  • Eczema
  • Nonspecific dermatitis
  • Lichenoid dermatoses
  • Lupus
  • Vitiligo
  • Leprosy
  • Fungus (histoplasmosis, coccidioidomycosis, etc.)
  • Mycosis Fungoides

Case Question: What is the diagnosis and which virus is associated with the development of this condition?

Mycosis fungoides

A type of cutaneous T-cell lymphoma, is characterized by the proliferation of neoplastic cluster of differentiation 4 (CD4) and T-lymphocytes in the skin. Mycosis fungoides and its leukemic variant, Sézary syndrome, are a rare form of non-Hodgkin’s lymphoma. Patients typically present with a mixture of progressive cutaneous manifestations, such as patches, plaques, tumors, and skin lesions. Both diseases have a poor prognosis in later stages. The first image demonstrates fungating tumors overlying hyperpigmented patches and plaques on the patient’s right arm with areas of purulent discharge concerning for infection.

This patient has experienced a superinfection of her persistent rash, due to underlying mycosis fungoides. Mycosis fungoides has no definite etiology but has been associated with human T-cell virus type 1 (HTLV-1).

Case Discussion

In this case, the diagnosis is difficult due to nonspecific skin presentations and a variety of skin disorders that may present similarly [1]. Pathologic examination is required for a definitive diagnosis. Treatment depends on the stage of the lymphoma but includes topical and systemic options. Topical therapies include mechlorethamine (nitrogen mustard), carmustine (BCNU), psoralen plus ultraviolet A (PUVA), ultraviolet B (UVB), and localized skin electron radiotherapy. Systemic therapies include interferon, vorinostat, and chemotherapy [2].

Take-Home Points

  • Cutaneous T-cell lymphoma is an uncommon skin disorder that can mimic many benign processes, particularly in its early stages.
  • Early identification and referral to dermatology is needed to facilitate diagnosis and management.

References

  1. Kelati A, Gallouj S, Tahiri L, et al. Defining the mimics and clinico-histological diagnosis criteria for mycosis fungoides to minimize misdiagnosis. Int J Womens Dermatol. 2017;3(2):100–106. PMID: 28560304
  2. Al Hothali GI. Review of the treatment of mycosis fungoides and Sézary syndrome: A stage-based approach. Int J Health Sci (Qassim). 2013;7(2):220–239. PMID: 24421750

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Author information

Monica Mitta

Medical Student
University of South Alabama College of Medicine

|

The post SAEM Clinical Image Series: The Insidious Rash appeared first on ALiEM.

Go to full site