Monday, 8 June 2009

A Case For June 2009: Back with a difficult case!

Dear Bloggers

I am so sorry I have not been keeping up the blog. Life has been somewhat busy ! However, I have a great case for you. Have a go at trying to answer it. Answers in the near future.

A 43 year old Caucasian hospital secretary presented to a hospital with the following:
  • Skin rash
  • Fever
The lady was usually in good health when she developed an acute rash that commenced on her neck, and progressed to her face, trunk and upper + lower extremities over several days.

The rash was not painful or itchy. She described the rash a 'spotty', 'red' and 'knobbly'.

She went to see her local doctor who thought she might have an infection and prescribed her oral aciclovir and ciprofloxacin. However, rather than the rash regressing, it progressed rapidly at the dismay of the patient. Two days after receiving the antimicrobial therapy the patient developed a low grade fever of 37.6 degrees. The patient attended her local doctor again who referred her to the internal medicine team of the general hospital.

Her only previous history had been a mastectomy for carcinoma of the right breast in 1995 with dissection of 1 lymph node. She had been treated post-operatively with radiotherapy and chemotherapy (chemoradiation). She had been deemed disease free at her last outpatient follow-up.

She had one child aged 10 years old born via a normal vaginal delivery. Her periods were regular every 28 days with 5 days bleeding. Her last menstrual period had been one week before (which had been normal) and she denied pregnancy. She used barrier contraceptive with her husband. She and her husband were monogamous.

She had otherwise been well with no recent infection. She had not traveled recently, there were no pets at home and no recent contact with animals. She had no contact with patients in the hospital where she was employed. Other members of her family were unaffected. She had no unusual hobbies.

She denied taking any medications, herbal supplements or over-the-counter (OTC) drugs prior to the onset of her symptoms. Her daily food intake had not changed. She denied using any new jewellery or washing powders.

She had no relevant family history. She was a non-smoker and drank alcohol only occasionally.

On review of systems, she denied any cardiovascular, respiratory, abdominal, musculoskeletal, urogenital, CNS-PNS or endocrine symptoms. She particularly denied weight loss, appetite change or night sweats.

On Examination

VITAL SIGNS: BP 120/80mmHg, Pulse 108 / min & regular, Respiratory Rate 14/min, T 37.4 degrees C, SpO2 98% breathing ambient room air.

GENERAL: Looked well but slightly shaky. No JACCOL

HEENT - Nil focal except for rash (see below). No goitre.

CVS - Pulse volume and quality: normal, JVP not elevated, no carotid bruits, No heaves or thrills, S1 + S2 present, No S3 or S4, gallop or pericardial rub. Peripheral pulses present throughout. No evidence of DVT in the lower limbs.

RESP: No tracheal tug or deviation. Normal chest expansion. Percussion resonant. Normal vesicular breath sounds.

ABDOMINAL: Soft, non-tender, no masses or organomegaly. No hernial orifices and no groin lymphadenopathy. Rectal exam was not performed.

BREAST EXAM: Left breast normal - no masses, no skin abnormality, no abnormal nipple discharge and no axillary lymphadenopathy. Right mastectomy scar present. No evidence of recurrence. No axillary lymphadenopathy.

SKIN: The following pictures show the rash. The lesions were circular, purplish, discrete, raised with an umbilicated central area. The maximum diameter was about 1cm. The lesions began as smaller discrete nodules that rapidly expanded -- please see the yellowish smaller nodules in the lower part of the picture (below)

After several days, existing lesions developed a necrotic centre with circumferential erythema. The lesions eventually crusted over leaving large areas of eschar from involuting coalesced lesions over the shoulders and proximal lower limbs. Fresh lesions continued to develop.


1) From the history and physical examination what would be your likely differential diagnosis?

2) What are the two most important tests to confirm the diagnosis?

3) What is your chosen treatment?

4) What addition problem should you consider screening for in this patient?

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