Arch Dermatol -- Archives of Dermatology Clinical Challenge

Bullae, Scaly Papules, and Plaques

REPORT OF A CASE

A 59-year-old African American woman with a history of hypertension and diabetes mellitus was referred to the dermatology department for treatment of a pruritic skin condition of 1 week’s duration that began on her hands and spread to involve the arms, trunk, and lower extremities. She later developed blisters on the soles of her feet and had difficulty walking because of the pain. Her medications included pioglitazone hydrochloride, hydrochlorothiazide, sucralfate, lisinopril, and hydrocodone with acetaminophen.

Physical examination revealed several erythematous scaly papules coalescing into plaques on the trunk, lower extremities, and dorsum of hands (Figure 1) and hyperkeratotic scaly plaques on the palms and soles. The patient also had a few erosions and tense bullae on her upper and lower extremities (Figure 2; the arrow indicates the tense bulla on the right medial palm). A biopsy of the left lower extremity with a tense bulla was performed, and a specimen was sent for hematoxylin-eosin staining (Figure 3). A subsequent biopsy specimen of the right upper arm was sent for direct immunofluorescence. Findings from a complete blood cell count, liver function tests, rapid plasma reagin, and human immunodeficiency virus tests were within reference range or negative for disease. However, she was positive for the hepatitis C antibody.

What is your diagnosis?

Figure 1.
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Figure 2.
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Figure 3.
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Please e-mail your diagnosis to dermquiz{at}ama-assn.org. You must include your full name, mailing address, and institutional affiliation in the initial e-mail to be eligible to enter the quiz. The first correct respondent will be acknowledged on this site next month and in print in Archives of Dermatology and will also receive a free copy of The Art of JAMA II.

For a complete presentation of this case and an in-depth discussion of the entity, please see next month's edition of the Archives.

Congratulations to the winner of our February quiz, Melvin Chiu, MD, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles.

The correct answer to our February challenge was LEOPARD syndrome (LS) associated with multiple granular cell tumors (GCTs).

For a complete discussion of this case, see the Off-Center Fold section in the March Archives (Gunson TH, Hashim N, Sharpe GR. Generalized lentiginosis, short stature, and multiple cutaneous nodules. Arch Dermatol. 2010;146[2]:337-342).

Next month's quiz will be available on April 19, 2010, at 3 pm Central time.

For comments or suggestions about the Archives Clinical Challenge, please contact us at jama-comments{at}jama-archives.org.
Ashish Bhatia, MD, Web Editor, Archives of Dermatology.

Vol 146, No 3, March 2010

Archives Clinical Challenge: You Make the Diagnosis


	Vol 146, No 3, March 2010 Archives Clinical Challenge: You Make the Diagnosis Bullae, Scaly Papules, and Plaques REPORT OF A CASE A 59-year-old African American woman with a history of hypertension and diabetes mellitus was referred to the dermatology department for treatment of a pruritic skin condition of 1 week’s duration that began on her hands and spread to involve the arms, trunk, and lower extremities. She later developed blisters on the soles of her feet and had difficulty walking because of the pain. Her medications included pioglitazone hydrochloride, hydrochlorothiazide, sucralfate, lisinopril, and hydrocodone with acetaminophen. Physical examination revealed several erythematous scaly papules coalescing into plaques on the trunk, lower extremities, and dorsum of hands (Figure 1) and hyperkeratotic scaly plaques on the palms and soles. The patient also had a few erosions and tense bullae on her upper and lower extremities (Figure 2; the arrow indicates the tense bulla on the right medial palm). A biopsy of the left lower extremity with a tense bulla was performed, and a specimen was sent for hematoxylin-eosin staining (Figure 3). A subsequent biopsy specimen of the right upper arm was sent for direct immunofluorescence. Findings from a complete blood cell count, liver function tests, rapid plasma reagin, and human immunodeficiency virus tests were within reference range or negative for disease. However, she was positive for the hepatitis C antibody. What is your diagnosis? Figure 1. View a larger version of Figure 1 Figure 2. View a larger version of Figure 2 Figure 3. View a larger version of Figure 3 Please e-mail your diagnosis to dermquiz{at}ama-assn.org. You must include your full name, mailing address, and institutional affiliation in the initial e-mail to be eligible to enter the quiz. The first correct respondent will be acknowledged on this site next month and in print in Archives of Dermatology and will also receive a free copy of The Art of JAMA II. For a complete presentation of this case and an in-depth discussion of the entity, please see next month's edition of the Archives. Congratulations to the winner of our February quiz, Melvin Chiu, MD, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles. The correct answer to our February challenge was LEOPARD syndrome (LS) associated with multiple granular cell tumors (GCTs). For a complete discussion of this case, see the Off-Center Fold section in the March Archives (Gunson TH, Hashim N, Sharpe GR. Generalized lentiginosis, short stature, and multiple cutaneous nodules. Arch Dermatol. 2010;146[2]:337-342). Next month's quiz will be available on April 19, 2010, at 3 pm Central time. For comments or suggestions about the Archives Clinical Challenge, please contact us at jama-comments{at}jama-archives.org. Ashish Bhatia, MD, Web Editor, Archives of Dermatology.