1/10. Photodistributed blue-gray pigmentation of the skin associated with long-term imipramine use.A 72-year-old white woman presented with progressively increasing slate-gray pigmentation of the face and extensor aspect of the forearms, which she had been suffering from for 8 years. She had been taking imipramine for approximately 30 years. Her other medications included ranitidine and anacin. physical examination revealed slate-gray hyperpigmentation of the skin photodistributed on the face (Figs 1, 2) and extensor aspects of the forearms. Relative sparing of the skin folds, mucous membranes, sclerae, teeth, and nails was noted. The remainder of the physical examination revealed no abnormalities. skin biopsy specimens from the right cheek and right forearm were obtained. Histologic examination revealed collections of variably sized, round to ovoid, yellow-brown globular deposits in the upper and mid dermis (Fig. 2). The deposits were identified within macrophages and free within the dermis. The epidermis was unremarkable and free of deposits. The deposits stained for melanin with a Fontana-Masson stain, but did not stain for iron.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/10. Cutaneous hyperpigmentation induced by doxycycline: histochemical and ultrastructural examination, laser microprobe mass analysis, and cathodoluminescence.skin hyperpigmentation induced by minocycline is a well-recognized side effect of minocycline but has rarely been reported for other tetracyclines. Based on a previously reported unusual case of chronic doxycycline abuse in a psychotic patient, we have investigated the nature of the observed pigment changes in the same patient. Histopathologic investigation of lesional skin by light microscopy disclosed hyperpigmentation of the basal keratinocytes and pigment-laden histiocytes in the dermis and subcutaneous fat. Only the pigment in the histiocytes of the upper dermis was reactive for Fontana Masson stain and could be bleached by hydrogen peroxide. The other histiocytes contained iron and calcium deposits as shown by von Kossa and Perls staining as well as by laser microprobe mass analysis. Ultrastructurally, these histiocytes contained amorphous material within the cytoplasm and stored in lysosomal structures. Comparative cathodoluminescence disclosed the presence of doxycycline in affected skin by means of overlapping emission spectra between the patient's skin and pure doxycycline. Taken together, the histomorphologic and ultrastructural changes induced by doxycycline shared several features with cutaneous hyperpigmentation caused by minocycline. Our biophysical findings further suggest a direct deposition of doxycycline, probably chelated with iron and/or calcium, within the lesional skin. Based on the presented unique case and the reviewed literature, only suprapharmacologic doses of doxycycline may be sufficient to cause such pigment changes.- - - - - - - - - - ranking = 0.063400911667697keywords = physical (Clic here for more details about this article) |
3/10. Segmental pigmented purpura.A segmental distribution of pigmented purpura (PP) is rare. Our patient presented at 5 years of age with red-brown petechial macules and telangiectases on her chest, the inner and dorsal aspects of the right upper extremity, and the dorsal aspect of the hand, which had developed slowly over the previous 7 months. The lesions were intermittently pruritic. A biopsy from the right arm revealed discrete hydropic degeneration of the basal layer of the epidermis, dilation of the blood vessels, numerous extravasated erythrocytes and lymphocytes, and lymphocytes in the lower part of the epidermis. The skin disease resolved almost completely within 18 months. The general physical examination revealed an open foramen ovale, slight hypogammaglobulinemia (G and A), and enhanced fragility of the blood vessels.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/10. Pigmented bowen's disease mimicking cutaneous melanoma: clinical and dermoscopic aspects.BACKGROUND: Pigmented bowen's disease (BD) (squamous cell carcinoma in situ) has been rarely described among white patients. OBJECTIVE AND methods: We report the case of a 48-year-old white male presenting a lesion of pigmented BD on his left thigh, clinically mimicking a superficial spreading melanoma. RESULTS: Naked-eye physical examination revealed a single 1.8 x 1.5 cm, hyperpigmented plaque with a rough surface, which appeared irregularly shaped and sharply demarcated. The assessment of this uncommon tumor by means of dermoscopy, never reported in literature before, was performed. According to standardized terminology, none among the well-established dermoscopic criteria useful to discriminate between melanocytic and nonmelanocytic origin was detected within the lesion. A reticular pigmentation simulated remnants of atypical pigment network, being of uncertain diagnostic value in the preoperative classification of the lesion. Other recognized patterns were irregular, brown globular structures and wide regression-like areas. None of the features diagnostic for pigmented basal cell carcinoma was found as well. CONCLUSION: The correct classification of nonmelanocytic origin of the lesion was therefore achieved only at histologic examination, after the complete surgical excision. In spite of its rarity, pigmented BD should be included among those lesions, which may simulate cutaneous melanoma. According to criteria validated by literature, dermoscopy failed to improve a preoperative classification of this peculiar skin tumor.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
5/10. Acrokeratosis paraneoplastica (Bazex syndrome): an atypical presentation.A 62-year-old male presented with a 2-year history of hyperkeratotic lesions of the hands and feet. Previous treatment with topical steroids was unsuccessful. A complete physical examination revealed the presence of blood in the stool, and sigmoidoscopy showed an ulcerative growth at the rectosigmoid junction. The histopathology showed adenocarcinoma.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
6/10. Longitudinal melanonychia of the toenails with presence of Medlar bodies on biopsy.A 9-year-old girl presented with a 2-year history of pigmented streaks on her second right toenail as well as on her fourth and fifth left toenails. The patient was otherwise asymptomatic with no other physical findings. Owing to parental concern, a biopsy was performed, which revealed numerous bacteria as well as Medlar bodies overlying the nail bed with no evidence of a nevomelanocytic lesion. To our knowledge, this is the first report of Medlar bodies causing pigmented streaks in the toenails.- - - - - - - - - - ranking = 0.063400911667697keywords = physical (Clic here for more details about this article) |
7/10. Atypical presentation of shock from acute adrenal insufficiency in an adolescent male.OBJECTIVE: To report an atypical presentation of shock and acute adrenal insufficiency in an adolescent male. CASE SUMMARY: A 14-year-old boy with a history of nocturnal enuresis presented with a clinical picture suggestive of septic shock refractory to aggressive fluid and vasopressor management. History and physical examination were suggestive of shock secondary to an infectious etiology, associated with skin findings of hyperpigmentation. The laboratory studies were remarkable for normal sodium, potassium, glucose, as well as normal renin levels. hydrocortisone therapy led to improvement of his blood pressure and allowed weaning of vasopressor medications. Further laboratory studies, including adrenocorticotropic hormone stimulation test and adrenal antibodies, confirmed the diagnosis of primary adrenal insufficiency. CONCLUSION: Acute adrenal insufficiency is an uncommon cause of shock in the adolescent population. We report a clinical presentation suggestive of shock secondary to acute adrenal insufficiency remarkable for an atypical clinical and laboratory presentation. We further provide information on the management of acute adrenal crisis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
8/10. Video game induced knuckle pad.Controversy and concern surround the video game playing fascination of children. Scientific reports have explored the negative effects of video games on youth, with a growing number recognizing the actual physical implications of this activity. We offer another reason to discourage children's focus on video games: knuckle pads. A 13-year-old black boy presented with an asymptomatic, slightly hyperpigmented plaque over his right second distal interphalangeal joint. A punch biopsy specimen confirmed knuckle pad as the diagnosis, and a traumatic etiology from video game playing was suspected. Knuckle pads can be painful, cosmetically unappealing, and refractory to treatment. They can now be recognized as yet another potential adverse consequence of chronic video game playing.- - - - - - - - - - ranking = 0.063400911667697keywords = physical (Clic here for more details about this article) |
9/10. Severe, chronic anorexia and extensive leg ulcerations as presenting signs of primary sjogren's syndrome.We report the case of a 75-year-old woman with a 15-year history of inappetance resulting in weight loss of approximately 40 kg. On physical examination, the skin of the lower extremities was markedly hyperpigmented with a brown-greyish hue. In addition, the skin of the legs was infiltrated, erythematous, riddled with erosions and necrotic ulcers. Clinical and laboratory evaluation revealed sicca syndrome, a pronounced polyclonal hypergammaglobulinemia (60 g/l), high levels of antinuclear, anti-SSA and anti-SSB antibodies. Histological examination of involved skin demonstrated a leukocytoclastic vasculitis.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
10/10. Male cases of incontinentia pigmenti: case report and review.Male patients with Bloch-Sulzberger incontinentia pigmenti (IP type II) are rare and more severely affected than their female counterparts, with a significant occurrence of sex chromosome aneuploidy. This document introduces a new male IP type II patient and reviews 48 males reported with IP. Twenty-eight of the 49 patients meet current criteria for diagnosis of IP type II. The phenotype is variable and the incidence of documented developmental delay is 25%. Five patients had klinefelter syndrome (47,XXY). Most patients were reported prior to 1961 when chromosome analysis was not available. biopsy and laboratory reports considered to be "consistent with" the diagnosis of IP were seen in patients meeting criteria as well as those who would not currently be given the diagnosis. The histologic findings considered diagnostic are varied. This variability may be accounted for by differences in stage of disease, biopsy site, histologic technique, and reporting style. Conversely, this may indicate that the diagnostic weight given to the biopsy should be reconsidered. eosinophilia was not a consistent finding. overall, differences in reporting, ascertainment, and length of follow-up lead to difficulty in interpreting or predicting the natural history of males with IP type II. Based on the existing literature, they appear to have a higher rate of mental retardation than the general population, but there does not appear to be a correlation between severity of physical and mental involvement. The presence of sex chromosome aneuploidy documented in the more recent cases emphasizes the need for chromosome analysis in any male patient suspected of IP type II.- - - - - - - - - - ranking = 0.063400911667697keywords = physical (Clic here for more details about this article) |
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