nenatuta1
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Intectious question!!!
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08.12.07 (11 months ago)
#1
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A 55-year-old man of Indian descent returns to your clinic for the third time this month. He is frustrated with his extremely pruritic rash, which has not responded to the strong topical steroid cream prescribed for him. He also complains of a 15 pound weight loss in the past 2 months and low-grade fever. He is divorced, lives with his 2 young daughters, and has not returned to India in the past 18 years. He denies any sexual contacts within the last 5 years and tells you this rash is a flare of malaria, which he had over 18 years ago. Full skin examination reveals approximately 80% total body surface area covered with lichenified, erythematous, eczematous plaques. There are no burrows or scales overlying the plaques. There is no involvement of the web spaces or lateral border of the fingers. Routine complete blood count 1-month prior showed a white count of 1,500/mm3 with 8% eosinophils. The diagnostic study most likely to help establish this patient's diagnosis is
A. antinuclear antibody level
B. HIV and CD4 count
C. IgE level
D. malaria prep
E. scabies prep
Explanation:
The correct answer is B. HIV and CD4 count are important in this setting of low total white count in a male with severe pruritus unresponsive to topical steroid. Treatment of idiopathic pruritus in HIV-positive patients is frequently a dilemma for many physicians. It is commonly recalcitrant to topical corticosteroid. Occasional success has been reported with ultraviolet light therapy. The most critical point is to recognize the correlation of pruritus associated with an early diagnosis of HIV.
Antinuclear antibody (choice A) is incorrect because there is no indications the rash is photo exacerbated. Lupus erythematosus lesions are not usually pruritic.
IgE level (choice C) is incorrect because atopic dermatitis, which can be associated with an elevated IgE level, usually responds to topical corticosteroid. In addition, atopic dermatitis is usually not associated with low white count and weight loss.
Malaria prep (choice D) is incorrect because malarial infection typically presents with cyclic high temperature fever. Generalized rash is not part of the usual manifestation.
Scabies prep (choice E) is a skin disorder caused by Sarcoptes scabiei, which is spread primarily by person-to-person contact. The most common symptom is pruritus, which most commonly occurs on the hands, waist, and genital areas. This patient's skin exam did not reveal any burrows or involvement of web spaces/lateral borders of fingers, which are common presentations of scabies.
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