Skin Case Studies

Skin Case Studies - Part I

CASE 1
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A 7-year-old boy has a history of intermittent allergy and sinus problems characterized by watery eyes, rhinorrhea, and a feeling of fullness in the front part of his face and nose. One day, the boy's mother notices that he has developed a persistent cough. When she asks him how he feels, he says that his head hurts and that his mouth tastes nasty. A quick check of his temperature indicates that he has a low-grade fever. The boy's mother figures that this is just another allergy-related incident and gives the boy an antihistamine.

The next morning, the boy awakens with a severe headache and is unable to open his right eye. He obviously feels very ill, so his mother immediately takes him to the family pediatrician. The boy's vital signs are normal except for the fever (which is now 39.1ºC). On physical examination, the right eyelids and the area around the right eye are obviously swollen and erythematous. When the lids are retracted, the eye appears to be displaced downward. There is considerable pain on palpation of the eye. When the boy is asked to move the eye, he says that he can't move it very much and that it hurts when he tries to move it. Except for a small quantity of exudate emanating from the eyelids, there are no other remarkable physical findings.

Question 1.1: What is your preliminary diagnosis?

Question 1.2: How is the diagnosis confirmed?

Question 1.3: How do you identify the causative agent?

Question 1.4: How did the causative agent get to this part of the body?

Question 1.5: How do the major symptoms come about?

Question 1.6: What other agents cause this disease?

Question 1.7: How should you treat this case?

Question 1.8: When are you most likely to see this disease?

Question 1.9: What complications are possible?

CASE 2

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A three-year-old boy lives in a very rural part of south Florida. His family is quite poor, so both of his parents (who dropped out of school in the seventh grade) have to work two jobs whenever they can. Because of this, the boy and his five siblings do not receive a great deal of attention, and their personal hygiene tends to be somewhat lacking. One day in late July the boy develops a series of red papules around his mouth and nose. By the next day, these papules have evolved into vesicles and pustules. Over the next 18-24 hours, the lesions start to break down, coalesce, and form thick, amber-colored, honeycomb-like crusts. The boy is not in pain and he doesn't really feel ill at all. Nevertheless, his face looks a little scary, and no one in the family has any idea of what the problem is or whether it might be contagious. As a result, it is decided that the boy's mother will take some time off from work and bring him to a local indigent clinic. The boy's vital signs are normal and there are no remarkable physical findings aside from the skin lesions.

Question 2.1: What is your diagnosis?

Question 2.2: What tests should you perform?

Question 2.3: What is the likely causative agent?

Question 2.4: How did this disease develop?

Question 2.5: What are the epidemiological characteristics of this disease?

Question 2.6: Are any serious complications possible?

Question 2.7: How should you treat this case?

Question 2.8: What is the prognosis?

CASE 3

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A 24-year-old man who regularly bites his fingernails accidentally tears out a small piece of the corner of the nail on his right index finger. The damaged skin starts to bleed lightly, so the man presses on the area with a tissue until the bleeding stops. Two days later, the man notices that the finger has become infected. A small area of skin near the corner of the nail is red and swollen. The skin is yellowish-white in the center of this area, where the swelling is most noticeable. The man, who knows just enough about infections to be dangerous, opts to treat himself. He "lances" the center of the swollen area with a needle that he sterilized by heating it in a candle flame. Pus then oozes out of the opening, confirming the presence of infection. The man presses and squeezes the area around the infection to force as much of the pus out the injured area as he can. He removes the exuded pus with a sterile cotton ball, cleans the finger with a topical antiseptic and covers the area with a small bandage.

Five days later, the man develops a fever and severe pain in his forearm. His arm is swollen, red, and warm to the touch, so he gets worried and goes to the nearby walk-in clinic for advice. On examination, he appears sweaty and hot. His temperature is 40.4ºC. There is a patchy red rash with poorly delineated edges on his right arm. The rash extends from the elbow to the shoulder. Lymph nodes in the axilla are enlarged and tender. The physician takes the patient's recent history and learns about the nail infection incident.

Question 3.1: What is your diagnosis?

Question 3.2: What are the most likely causative agents?

Question 3.3: How can you identify the causative agent?

Question 3.4: Does this agent cause any similar diseases?

Question 3.5: What other agents cause this disease?

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