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A51-year-old man who was an active injection drug user was admitted to the ICU with septic shock and severe respiratory distress. Notable findings were fever, multiple opacities on a chest radiograph, and an elevated white blood cell count.

Septic Pulmonary Emboli

A 3-year-old boy is seen for unilateral swelling on the left side of the face, in front of and behind the left ear. Findings on examination of ears, oral cavity, and teeth are normal. He is afebrile (temp, 37°C [98.6°F]), cooperative, and in no distress. He is otherwise healthy. Past medical history includes 1 MMR vaccination.

The child is bright and alert and has no fever. The swelling is on the left side of the face only. Find other clues to a diagnosis in the accompanying video.  

3-Year-Old Boy With Unilateral Facial Swelling 

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. She has a history of multiple non-melanoma skin cancers.

Squamous cell carcinoma in situ (Bowen  disease)

Lichenoid keratosis (an inflammatory variant of seborrheic keratosis)

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. What does this look like to you?

Clinical Topics

What's This "Red Spot"?

A 43-year-old woman presents to the dermatology clinic with complaints of a rash of one weeks’ duration. The first lesion started on the left breast (at right), then scabbed over. About 4 days later, fever, chills, neck pain, and headache abruptly started. The fevers spiked to 102°F. A tender rash then disseminated to involve the face, trunk, and extremities. She denies muscle or joint pain, vomiting, sore throat, diarrhea, or dysuria. The patient reports no other sick contacts.

She lives in an apartment in Brooklyn, New York, and denies recent travel. She works as a cook. She is monogamous with her male partner and lives with 2 children. The patient’s 2-year-old daughter has a similar lesion on her right thigh, but denies other symptoms. The patient had chickenpox in childhood and denies a history of herpes. On questioning, the patient reports that she had called an exterminator 2 weeks ago to deal with a “mouse problem.”

Physical exam is significant for an erythematous plaque with an eschar on one breast. Grey pustulovesicles on an erythematous base can be found on the dorsal hands (image at right), face, arms, legs, and flank. The oral mucosa is clear.

Rash began with one lesion followed by tender, disseminated eruption; fevers spiked to 102°F. Test your visual diagnostic skills. 

Image IQ: Rash with Chills, Neck Pain, Acute Fever  

A 64-year-old woman with a history of basal cell carcinoma presents to the dermatologist for skin cancer surveillance. She is incidentally noted to have bruising on her upper eyelids (above). On questioning, she reports experiencing recurrent intermittent eyelid bruising for several years. She denies a history of trauma to her face, pain, or other associated symptoms.

Her medical history is significant for hyperlipidemia, hepatitis C (diagnosed >30 years earlier), osteoporosis, celiac disease, and idiopathic proteinuria for several years. Her surgical history includes appendectomy and carpal tunnel repair.

Pertinent family history includes her mother dying of multiple myeloma and her father of complications of diabetes.

Review of systems is significant for vague symptoms of gastrointestinal discomfort. On more directed questioning, she reports the eyelid purpura is temporally related to the Valsalva maneuver/ strained bowel movements. Her medications include atorvastatin, risedronate sodium, a daily multivitamin, calcium, vitamin D, and aspirin.

Her examination reveals no bruising elsewhere and no findings of interest on skin or mucous membranes.

B. Allergic contact dermatitis, purpuric type

Eyelid bruising was observed on a 64-year-old woman during routine skin cancer follow-up. She denied trauma or pain. What does this look like to you? 

Image IQ: Recurrent Eyelid Purpura 

The mother of a 10-year-old boy brings him in for evaluation of his moles (which are all benign). During the visit, the mother asks about the lesions on the first 2 knuckles of his right hand; she initially noticed them several months earlier. The boy is otherwise healthy.

White Knuckles

A 13-year-old girl with known eczema presents with a vesicular rash on her palms that appeared after swimming in the ocean. Skin is tender; vesicles ooze clear liquid. Treated with triamcinolone w/o effect. Watch real-time examination on video.

A. Acute palmoplantar eczema (dyshidrotic eczema)

VIDEO: The child's hands are chronically dry but the skin has recently begun to crack; vesicular rash appeared after an ocean swim. Dx?

A 13-year-old Girl with a Vesicular Rash on Palms 

Alexey Amchentsev, MD

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