A 45-year-old woman presents with the complaint that her toenails are thick and yellow. She is otherwise healthy and takes no medications. On examination, two toenails on the right foot and the great toenail on her left foot are affected. There is no periungual erythema, and her peripheral pulses are good.
What is the best advice for this patient?
This woman has onychomycosis, which often affects the toenails in an asymmetric pattern. Onychomycosis does not usually resolve spontaneously and is more difficult to eradicate than is tinea pedis (athlete’s foot). The etiologic agents include several species of yeast, mold, and dermatophytes, therefore, direct microscopy and/or fungal culture may be necessary for definitive therapy. The condition is often asymptomatic and may not require treatment. Topical therapies are effective against early onychomycosis, but require daily application for many months. Oral treatment with terbinafine or itraconazole is more effective than topical treatment but must also be continued for 3 to 4 months; oral antifungals carry the risk of hepatotoxicity. Yellow nail syndrome should be considered in the differential for widespread yellow nail changes and is associated with pulmonary disease and cancers. Yellow nail syndrome affects all 20 nails; a workup for systemic disease is unnecessary in the usual patient with onychomycosis.
A 33-year-old fair-skinned woman has telangiectasias of the cheeks and nose along with red papules and occasional pustules. She also appears to have conjunctivitis with dilated scleral vessels. She reports frequent flushing and blushing. Drinking red wine produces a severe flushing of the face. There is a family history of this condition.
Which of the following is the most likely diagnosis?
Rosacea is a common problem in middle-aged, fair-skinned people. Sun damage appears to play an important role. Stress, alcohol, and heat contribute to the flushing. Men may develop rhinophyma (connective tissue overgrowth, particularly of the nose). Low-dose oral tetracycline, erythromycin, andmetronidazole control the symptoms. Topical metronidazole also works well. The carcinoid syndrome causes flushing but not papules and pustules and is usually associated with gastrointestinal symptoms; it is quite rare. PCT can cause telangiectasias and can be associated with alcohol consumption, but patients with this disease usually have increased facial hair growth and fragile skin in sun-exposed areas as well. The butterfly-shaped macular rash of lupus does not cause pustules; usually the patient has other evidence of active disease, especially synovitis. Seborrheic dermatitis affects the eyebrows and nasolabial folds more prominently than the cheeks and nose.
A 46-year-old construction worker is brought to the clinic by his wife because she has noticed an unusual growth on his left ear for the past 8 months (see photo below). The patient explains that, except for occasional itching, the lesion does not bother him. On physical examination, you notice an 8-mm pearly papule with central ulceration and a few small dilated blood vessels on the border.
What is the natural course of this lesion if left untreated?
This is a classic description of basal cell carcinoma. Basal cell carcinoma is a malignant neoplasm of the epidermal basal cells that clinically presents as a pearly papule or nodule with a central ulceration, raised borders, and telangiectasias. Basal cell carcinomas are locally invasive and rarely metastasize; distant spread is reported in fewer than 0.1% of these cancers. Invasion of surrounding tissue and metastasis are more frequently seen in squamous cell carcinoma. Squamous cell carcinoma is a malignant neoplasm of the keratinocytes; it is much more aggressive than basal cell carcinoma, grows rapidly, and may metastasize via lymphatic spread. Bacterial infections such as meningococcemia and necrotizing fasciitis could result in septicemia without appropriate treatment but are acute, not chronic, conditions.
A 25-year-old postal worker presents with a pruritic, nonpainful skin lesion on the dorsum of his hand. It began like an insect bite but expanded over several days. On examination, the lesion has a black, necrotic center associated with severe local swelling. The patient does not appear to be systemically ill, and vital signs are normal.
Which of the following is correct?
The possibility of cutaneous anthrax in this postal worker is the most important consideration in the era of bioterrorism concern. The lesion described would be characteristic of cutaneous anthrax—beginning as a small papule that is painless and progressing to a black, necrotic lesion over several days. A skin biopsy would show the very characteristic gram-positive rods of anthrax. Cutaneous anthrax has been shown to occur in postal workers who have handled letters containing anthrax spores, and can also occur in those who handle infected animals or their wool or hides. Unlike inhalational anthrax, these patients do not appear severely ill at the outset of the infection. Ecthyma gangrenosum also produces a black, necrotic skin lesion. These lesions occur in patients who are bacteremic and systemically ill from P aeruginosa. The brown recluse spider’s bite can also produce a black necrotic ulcer. The bite is painful and usually spreads rapidly. The bubo of plague produces a tender lymphadenitis. The patient with plague or necrotizing fasciitis is acutely ill with fever and other signs of systemic inflammatory response syndrome.
A 25-year-old man who has been living in Washington, DC, presents with a diffuse vesicular rash over his face and trunk. He also has fever. He has no history of chickenpox and has not received the varicella vaccine.
Which of the following information obtained from history and physical examination suggests that the patient has chickenpox and not smallpox?
Although there have been no cases of smallpox in the world since 1977, the threat of bioterrorism has forced physicians to be vigilant about the disease’s reemergence. It will be important for students and physicians to recognize the distinguishing characteristics of smallpox versus chickenpox. In smallpox, lesions are more likely to occur on face, palms, and soles. In chickenpox, lesions are more concentrated on the trunk. In smallpox, lesions are characteristically in the same stage of development. In chickenpox, lesions are more superficial, come out in crops, and are in many different stages of development. In smallpox, fever and prostration precede the rash by several days; patients appear severely ill. In chickenpox, fever usually occurs at the time of the appearance of the rash.
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