Tag Archives: Level A

A 19 year old albino with a skin lesion

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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

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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

An unwell lady with a history of breast cancer

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A 53 year old female presents to the Queen Elizabeth Hospital, Blantyre with a 2 day history of drowsiness, diarrhoea and vomiting.

Her past medical history includes hypertension, diabetes and recently diagnosed breast cancer.

On examination she is dehydrated, BP 95/60, pulse 120/min, temp 380C, O2 sats 90% on air and Glasgow Coma Score of 14/15 (E4V4M6).

  1. What other history is required?
  2. What diagnoses would you consider?
  3. What immediate tests are indicated?
  4. What treatment would you start?


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Is she on chemotherapy for her breast cancer? If so you would worry about the possibility of neutropenic sepsis.  Immediate tests would include a blood sugar level (quick to do and vital in anyone with a history drowsiness – and we know she has diabetes), urgent full blood count (FBC) and blood cultures.  Less urgent tests include a chest X ray, urine dipstick (send for microscopy and culture if indicated) and urea and electrolytes.

Intravenous (IV) fluids,  IV broad spectrum antibiotics and oxygen should be started as soon as possible.

FBC results: Hb 66, WCC 0.8, Plt 34.

This case was contributed by Ewan Brown and Leo Masamba.

 



A 4 year old boy with patchy hair loss

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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.

Further info

 

This case contributed by Levie Mwale and Ann Sergeant

 

A 22 year old man with a painful rash

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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.

Further info

This case contributed by Levie Mwale and Ann Sergeant

A 34 year-old man with a fit

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A 34 year old man presents to Queen Elizabeth Central Hospital, Blantyre with a 2 day history of frontal headaches and generalized tonic clonic seizures. His guardians report that he has had multiple nodules all over his body since childhood but has previously been well.

He has another prolonged seizure after admission. He is post-ictal on examination with a Glasgow Coma Scale 11/15 (E -4, V-2, M-5). His pupils are of normal size and equally reacting to light. His vital signs on admission are: blood pressure 121/81mmHg, pulse 94/min, temperature  37.0°C, respiratory rate 24/min. The chest and abdominal examination are normal. The rest of the neurological exam does not reveal  any focal deficits.

  1. What is his underlying condition?
  2. What differential diagnoses are you considering?
  3. What tests would you want to do?
  4. What would your initial management be?

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The recent history of headaches raises the possibility that this is more than simple epilepsy, though his underlying condition is associated with epilepsy.  This is a region where there is a high prevalence of HIV infection, the possibility of which broadens the differential diagnosis importantly.

His underlying condition is  neurofibromatosis type 1.  It is associated with epilepsy and with astrocytomas, gliomas, but at presentation it may be causative or just a coincidence.  

Tests you should seek:

  • Blood glucose
  • Full blood count
  • Malaria blood film
  • Lumbar puncture with examination to include India Ink stain (if available you would test for Cryptococcal antigen)
  • HIV test
  • Urea and electrolytes
  • Brain imaging (but CT /MRI not available here)
  • Serology for syphilis

Differential diagnosis

  • Epilepsy – simple or caused by neurofibromatosis-associated brain lesions
  • Cerebral malaria is more likely in children than adults
  • Metabolic – DEFG; Don’t ever forget Glucose.  Hypoglycaemia may induce coma and convulsions.  Other metabolic disturbances including hyponatraemia
  • Meningitis – particularly TB or Cryptococcal meningitis in the presence of HIV infection
  • Infective focal brain lesions:  Toxoplasmosis, primary CNS lymphoma – usually HIV-related; Cysticercosis, neurosyphilis

Initial management

  • Control continuing convulsions with diazepam IV.

Then in this setting:

  • Phenobarbitone 600mg loading dose (infusion or slow push) the 90mg maintenance (IM or orally if patient can tolerate it) OR Phenytoin 900mg loading dose (infusion) then 100mg tds maintenance.  Blood monitoring is not available.
  • Empirical cover for meningitis until CSF results back: Ceftriaxone 2g bd IV

For options in other centres, see …

This case contributed by Dr Tamara Phiri

 

A 16 year old girl with oedema

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A 16 year old girl presents to Queen Elizabeth Hospital, Blantyre with a two-month history of facial oedema.  It is worse in the morning, slightly better at night and not associated with shortness of breath or cough.  She has been well recently, with no intercurrent illnesses. Some kind of antimicrobial was prescribed a month ago, but the swelling was present then and has increased since.

On examination she is slim but has marked bilateral pitting pedal oedema and facial puffiness; her abdomen is also distended, with shifting dullness.  She is apyrexial.  General examination is unremarkable.  Her BP is 112/65, pulse 72.  She has reduced breath sounds and dullness to percussion at both lung bases.  Heart sounds and abdomen are normal and she has no neurological deficit.

A urine dipstick shows 4+ protein.  She has a serum creatinine of 60 micromol/l (0.7 mg/dl) and a normal blood count.  Tests of liver function, serum proteins are not available.

  1. What is the differential diagnosis?
  2. Renal biopsy is not immediately available here.  What management will you recommend?  How will you advise her and her parents?

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With 4+ proteinuria and oedema there can be little doubt that she has nephrotic syndrome.  It is ‘pure’ nephrotic syndrome, meaning heavy proteinuria without any haematuria, which puts it at the extreme left hand end of the spectrum (see Glomerulonephritis) and makes it significantly less likely that it is caused by post-streptococcal glomerulonephritis or other disorder more toward the ‘nephritic’ end of the spectrum.

She should severely restrict salt intake: oedema is caused by salt retention.  Diuretics are often required, usually loop diuretics.

HIV is an important condition in this region.  An HIV test is important both because the condition could be a manifestion of HIV affecting the kidney, and because most active treatments for nephrotic syndrome involve immunosuppressive agents.

Minimal change disease would be the most likely explanation in a Caucasian girl.  However FSGS is more common as a cause of nephrotic syndrome in Africans: one of these two conditions is most likely. SLE is very unusual before menarche.

If she is HIV negative, a trial of prednisolone, 1mg/kg/day for a few weeks would be worthwhile.

Further info

This case is was contributed by Fran Th’ng and Gavin Dreyer

Unilateral cysts as an incidental finding (14)

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A 79 year old gentleman had an abdominal ultrasound scan due to the incidental finding of abnormal LFTS.  This was reported to show slightly increased echogenicity of the liver in keeping with fatty infiltration.  He was also noted to have small, simple cortical cysts, with the largest measuring 36mm by 31mm, in his left kidney.  The visualised pancreas, aorta, right kidney, gall bladder and biliary tree all appeared normal and the spleen measured 9.8 cm, which was also normal.

The reason I write is to establish whether any further action is required regarding his cysts in his left kidney or whether in fact they can be ignored as they are not causing him any symptoms at present and should be viewed as an incidental finding only?

 What further information would you seek before giving your opinion?

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Results of investigations are as follows;

 Blood – Urea 7 / Creatinine 102 / eGFR >60 / Electrolytes within normal ranges

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This should be viewed as an incidental finding and you can essentially just ignore the result.  It is not an uncommon finding and not expected to give rise to any symptoms or indicate an adverse renal prognosis.  Of note, complex cysts can indicate malignancy but this is not what is being described here.

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Incidental finding of abnormal renal ultrasound (13)

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A 47 year old man recently had an ultrasound scan, and the report stated: right kidney could not be identified in the renal bed or right pelvic region. Left kidney =16.6cm, presumably due to compensatory hypertrophy. The left kidney appears normal in echopattern with no hydronephrosis or renal calculi. 

He is not aware of having had his kidney removed. The scan was requested as he had a dull ache in both renal angles and abdominal bloating.  He still gets a dull ache over his right loin a couple of times per week, lasting a few hours.  He does not need to take analgesia for this discomfort.  No aggravating factors.  He wonders himself if he could have pulled a muscle as he works delivering food.  He sometimes feels pulling in right groin when he bends forward.

Does he need any kind of follow up with regards to having 1 kidney, such as regular blood tests to check his kidney function?

 What further information would you seek before giving your opinion?

See more of the history or available results?

Results of investigations are as follows;

Bloods: FBC and U+Es normal

 BP: 148/87

We discussed lifestyle advice regarding his blood pressure, as he is not keen to start medication.  I have arranged to repeat the blood pressure reading in 2 months and if still elevated commence him on amlodipine.

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This man just needs sensible attention to general healthcare and cardiovascular risk.

Single kidneys are common and, as in this case, the opposite one compensates for the loss of the other.  He will almost undoubtedly do well but probably should know that anything else that comes along in the next few decades that injures kidneys e.g. worsening hypertension, diabetes, NSAIDS,etc should probably be looked at with care and attention.

I would treat his hypertension as you are doing and repeat his bloods perhaps yearly as you might do for anyone with hypertension.

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