A swollen leg

A 39 year old subsistence farmer is referred to the dermatology clinic with massive left leg swelling, present for several years.  His main complaint is of “leaking” and malodour, and he is reluctant to remove the tubifast dressing that he has applied himself.

What is the likely diagnosis?

What advice and treatment would you give?

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He has elephantiasis which is characterised by skin thickening and swelling of the underlying tissue leading to enlargement of his limb.  This is secondary to underlying problems with lymphatic drainage, and in this case the most likely cause is lymphatic filariasis.

The old bandages that he has applied should be removed and he should be shown/advised how to clean to reduce infection.  Emollients may be used to restore and maintain skin suppleness.

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Case contributed by Levie Mwale and Ann Sergeant

A 56 year old farmer with lip ulceration

A 56 year old farmer who lives in a village near Blantyre, Malawi, presents with painful oral ulceration which is making eating difficult.  On further questioning he also admits that he has pain on micturition as he has painful penile ulceration. You also see that he has inflamed conjunctivae.

He started antiretroviral drugs for newly diagnosed HIV infection 1 week ago (lamivudine, nevirapine and stavudine).

What diagnoses would you consider?

How would you manage him?

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It is important to examine the whole of the patient’s skin and mucous membranes to determine the extent of disease, and in this case this established that there was mucous membrane involvement only.

The most likely diagnosis is Stevens-Johnson Syndrome (SJS), an idiosyncratic drug eruption, with nevirapine being the most likely cause.  Other diagnoses to consider include immunobullous disease such as mucous membrane pemphigoid or pemphigus vulgaris, or inflammatory disease such as erosive lichen planus – these are rare conditions which follow a chronic course.  Although infections (eg. mucocutaneous herpes simplex virus infection) should be considered the involvement of all mucous membranes would make this very unusual.

It is important to stop the offending drug quickly, and so nevirapine was stopped and the patient was admitted to hospital.

Other measures are supportive: analgesia, mouth and eye care, antiseptics for skin/genital involvement, may require IV hydration/nasogastric feeding, may require catheterisation.  Long term complications include scarring of genitals (which may lead to phimosis) and scarring of eyes which in the worst cases may lead to blindness – treatment aims to avoid these complications.

In this case the following treatments were used: paracetemol was adequate for pain control, saline mouth washes, tetracycline eye drops, gentian violet as antiseptic to penile ulceration.  He was regularly assessed for signs of infection.  He was able to tolerate oral intake and did not require a catheter.  He was referred to the antiretroviral clinic to institute another drug to complete his HAART regime.  He developed no new lesions and his ulceration gradually improved to allow discharge from hospital.

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Case contributed by Levie Mwale and Ann Sergeant

A 19 year old albino with a skin lesion

A 19 year old lady from Blantyre, Malawi, attends with a scaly lesion which has been present on her right cheek for 3 months.

  1. Can you describe what you see?
  2. What is the diagnosis?
  3. What is your management?

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This is an albino woman with a small (approx 1 cm) superficial looking red scaly lesion on her right lateral cheek.  She has some lentigines (the brown marks) and coarse wrinkled neck skin.  If palpated the skin over the red lesion feels rough.

This is an actinic keratosis (actinic/solar – sunlight (UV) induced, keratosis – scaly/horny growth).  Considered to be pre-malignant, actinic keratoses are most often seen in exposed skin in fair skinned individuals who have had excessive UV light.

An actinic keratosis may follow 1 of 3 paths: it may regress, it may persist unchanged, or it may progress to invasive squamous cell carcinoma. The actual percentage that progress to invasive squamous cell carcinoma remains unknown, and estimates have varied from as low as 0.1% to as high as 10%.  Generally, thicker lesions are more likely to progress.

She should be advised to avoid further damaging sun exposure by wearing a wide-brimmed hat, clothing which covers the skin and a high factor sunscreen on exposed sites.  The actinic keratosis can be treated in several ways including medical management with creams and surgical management.  As she has several further actinic keratoses on her neck and other cheek (not seen in the photo above) and as other treatment modalities are not available in the clinic she is treated with imiquimod.  This is an expensive treatment, but had been donated to the clinic from an overseas organisation.

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A man with a foot ulcer

A 42 year old man attends the dermatology clinic in Queen Elizabeth Central Hospital, Blantyre in 2012 with an ulcer on the sole of his right foot.  He says that it has been present since 2004 but that he underwent surgery 1 and a half years ago.  He was told it was a squamous cell carcinoma.  It initially healed, but since then the skin has broken down and the ulcer is enlarging in size.  He went back to see the surgeons and they have sent him on to dermatology to get dressings.

  1. Can you describe what you see?
  2. What diagnoses would you consider? Is there any information that would be ideal to have that would help point you towards the most likely diagnosis?
  3. Would you like to examine any other part of his body?
  4. What would you do next?

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This is a deep, irregulary shaped ulcer on the mid-sole of the right foot.  There is no cm scale in the photo, but it must be at least 5 cm in diameter.  The ulcer looks relatively clean.  The base of the ulcer comprises of  red fleshy tissue.  It is not possible to see bone or tendons.

In this case the most likely explanation is recurrence of squamous cell carcinoma (SCC). It would be helpful to get his pathology report from his operation 18 months ago to confirm that it was SCC and to see whether it was completely excised at the time.

The differential diagnoses includes a neuropathic ulcer (this is less likely as the ulcer does not correspond to the area of sole with maximal pressure, and he has no history of neuropathy) and infection (which in this geographical setting may include fungi and mycobacteria: but note there is little discharge, swelling or surrounding inflammation).

You would want to examine his ipsilateral inguinal and femoral lymph nodes to check for signs of metastasis and if they are palpable a fine needle aspirate (or lymph node biopsy) should be sent to pathology.

A biopsy of the base of the ulcer for pathology would confirm or refute the diagnosis of recurrence of SCC.

A surgical opinion as to whether this is operable should be sought.

This case was contributed by Levie Mwale and Ann Sergeant

A 4 year old boy with patchy hair loss

A healthy 4 year old boy is brought to the Dermatology clinic at Queen Elizabeth Central Hospital, Blantyre by his parents.  He has been scratching his head, and they have recently noticed that he has developed several small scaly areas with associated hair loss.

What is your diagnosis and how would you treat him?

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The diagnosis is tinea capitis (scalp “ringworm”).  This is a cutaneous fungal infection which invades the hair shaft and is often due to Trichophyton tonsurans (caught from other children) or Microsporum canis (caught from kittens or puppies). Without treatment it gets better spontaneously at puberty.  After puberty it only occurs in patients with underlying immunosuppression.

Treatment of choice is oral griseofulvin 15-20mg/kg/day for 6 weeks.  Additional application of a topical antifungal, during the early stages of treatment, may reduce the risk of transmission.  Terbinafine is an unlicensed alternative, but may not be as effective for infections with M. canis.   The only oral antifungal available in the department is ketoconazole, so he is prescribed this and topical Whitfield’s ointment.  His parents then tell you that his elder sister was treated with the same treatment successfully earlier this year.

Other siblings with infection should also be treated and if the family pet’s fur is falling out it must be treated too.

The other differential diagnosis to consider in this case is alopecia areata but the presence of scale distinguishes these diagnoses.

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This case contributed by Levie Mwale and Ann Sergeant

 

A 22 year old man with a painful rash

A 22 year old plumber attends the drop-in clinic in the dermatology department at Queen Elizabeth Central Hospital, Blantyre.  He has a 1 day history of a painful vesicular rash on his right buttock and posterior thigh. He feels unwell with fever.

Right posterior thigh

  1. What is your diagnosis?
  2. What is your management?

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This is herpes zoster infection also known as “shingles”.  Varicella zoster virus (VZV) lies dormant in the posterior root ganglion after chicken pox.  Reactivation causes the virus to travel down the cutaneous nerves to infect epidermal cells in the skin.    The presence of pain and the dermatomal distribution is classical.  As the rash is less than 72 hours old it is worthwhile treating with antiviral medication such as aciclovir, famciclovir or valaciclovir, if available.  They inhibit VZV replication and reduce the severity and duration of the rash.  Postherpetic neuralgia (pain which persists >3months after the rash has resolved) is more common in elderly patients and may respond to tricyclic antidepressant drugs, which should be started early if possible.

He is treated with aciclovir 800mg 5 times daily for 7 days and regular paracetemol.

In a young man in an HIV prevalent region, underlying HIV should be suspected (Herpes zoster is categorised by the World Health Organisation as clinical stage 2 of HIV infection) and an HIV test performed.

His HIV test was positive.  His CD4 count should be checked and if ≤350 cells/mm3 antiretroviral therapy commenced.

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This case contributed by Levie Mwale and Ann Sergeant