Subacute progressive lesions | Figure 1

Subacute progressive lesions

... involving bilateral lower extremities (only shins and knees). The initial onset of multiple tender ulcerative lesions (1-2cm) began a few weeks prior while hiking in Germany, Denmark and Norway. He was careful about checking for ticks, no contact with animals (except once petting a stray cat), and stayed in Airbnbs, used jacuzzi once. Never had fever or other associated symptoms, basic labs were normal, and he did not respond to amoxicillin, clindamycin, steroids while in Germany (presumed erythema nodosum). The dark lesions (at various stages of progression) expanded and became more ulcerative, erythematous and painful until he presented for admission back in the US. PMHx: managed for #Crohns with 6MP and #adalimumab w/o a recent flare for ~13 years.

He was admitted for IV treatment of underlying cellulitis with vancomycin and the surrounding pain/erythema improved (photo #4). CRP: 10. ESR: 24. Fungitel neg, TB Quantiferon neg, HIV neg, HBV neg, histo Ag neg, anti-adalimumab Ab neg. A punch biopsy was sent from right ankle for fresh tissue culture, which had no growth, no AFB; and separate sample for path, which revealed #LeukocytoclasticVasculitis. (Underlying cause for LCV still not yet clear).

Update 1

P-ANCA negative. Histo serum and urine Ag neg. Completed 14 day course of antibiotics (vancomycin while inpatient—> TMP-SMX + cephalexin as outpatient). Lesions scabbed over, with underlying granulation. When cellulitis resolved, Humira was restarted, topical triamcinolone applied.

Diagnosis Added

Leukocytoclastic vasculitis due to underlying Crohn’s with superimposed cellulitis

A 37-year-old woman presented with recurring painful swelling and erythema of the vulva over the last year. Despite a series of negative vaginal cultures, she was prescribed multiple courses of antifungal and antibacterial treatments, while her symptoms continued to worsen. She had no other relevant medical history except for occasional diarrhea and abdominal cramping, which were attributed to irritable bowel syndrome. On examination, she had symmetric edema and erythema of the vulva. Closer inspection revealed a nonulcerated, slightly friable nodule of approximately 4 mm on her right labium minus. A biopsy of this region demonstrated multiple noncaseating granulomas and mixed inflammatory infiltrates. An acid-fast stain for mycobacteria was negative. Vulvar skin ultrasonography demonstrated fistulas and increased dermal thickness with altered subcutaneous tissue. She was encouraged to undergo colonoscopy, which showed findings suggestive of Crohn disease. This diagnosis should be considered in a patient who has vulvar pain, edema and ulcerations not otherwise explained, whether or not gastrointestinal Crohn disease is present. The diagnosis is established with clinical history and characteristic histopathology on biopsy. Multiple biopsies may be needed, and early endoscopy is recommended to establish the diagnosis. An imaging study such as ultrasonography is sometimes used to differentiate between a specific cutaneous manifestation of Crohn disease and its complications such as perianal fistula or abscess.

A 45-year-old woman presented with few weeks of crural skin erythema which is not tender, elevated or indurated. Lesions grew in size over days. He used some 3-in-1 cream (corticosteroid, antibiotic, antifungal) without improvement. Two days before current presentation she developed small "wound" of the similar small lesion as those above and in front of the lower leg, on her right heel which soon becomes big and transformed to big blister filled with serous fluid and was surrounded by erythema. The region below this blister is little edematous and the talocrural joint is painful and with limited range of motion which makes the patient have an antalgic walk. She had no fever or any other systemic symptoms. The whitish matter around the blister is a cream she put on. What would be diagnosis for both kind of lesions presented and are those same disease or different processes?

Male 76 years old with Ulcerative Colitis. Tx adalimumab for their condition. He develops this lesion.

A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?