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Dermatology Discussion

New York United Medical Center, New York

January 2005

Presenters:  Nilam Amin DO PGY-3, Marcy Alvarez DO PGY-2, Raymond Ramirez DO PGY-2
 

Program Director: Cindy Hoffman, D.O.


Clinical Presentation

60 years old Hispanic Male

History

Chief Complaint: “large, itchy bumps all over my body” x 3 days

Signs and Symptoms: Intense pruritus and pain at lesion sites
Denies burning, discharge, fever or other constitutional
symptoms

Previous Treatment: topical corticosteroids, blinded biologic trial drug for psoriasis (name unknown), phototherapy, and etanercept (Enbrel®)

Other Information: This patient was diagnosed with chronic plaque psoriasis in 1989. He had been treated with multiple different regimens without significant improvement. Three months prior to his presenting complaint, he was treated with etanercept 25 mg SQ injections BIW. He discontinued etanercept after two months of treatment secondary to complaint of severe headache. The patient presented to our clinic five months after discontinuation of the injectable biologic. He denies other psoriasis treatments between the time of discontinuation and the outbreak of his eruption. He denies household contacts with similar complaints, recent travel, or prior episodes of similar lesions.



Physical Examination

Multiple, large (ranging from 1-25 cm), discrete, well-defined, hyperkeratotic, hyperpigmented nodules and plaques on the scalp, face, trunk, and extremities.

There was no pre- or post-auricular, cervical, supraclavicular, or axillary lymphadenopathy noted.
 

Laboratory Tests

Basic Metabolic Panel: Within Normal Limits

CBC with differential: Within Normal Limits

ANA: negative ESR: 4 (mm/Hr) RPR: non-reactive

Hepatitis Panel: Anti-HCV: non-reactive Anti-HBcore: non-reactive
Anti-HBsAg: non-reactive HBsAb qual: non-reactive
HAV Ab total: Positive HAV Ab(IgM): Negative

Cellular Immune Panel: CD3%: 71 Abs CD3+: 1427
CD4%: 42 Abs CD4+: 844
CD8%: 30 Helper/Suppressor Ratio: 1.4

 

Dermatohistopathology

Histopathologic findings include eruptive hyperplasia with marked epidermal pallor, parakeratosis, numerous intraepidermal neutrophils, and thinning of the suprapapillary epidermal plate. The dermis shows evidence of edema, upward enlargement of the dermal papilla and dilitated, tortuous dermal capillaries. These findings are consistent with eruptive psoriasis.

Differential Diagnosis