CASE 7

A 35-year-old man, a highly stressed business executive from Birmingham, complains about a nasty lesion on his leg that won't go away. The man works about 90 hours per week and hates to take time off for things like visits to a physician, so he has tried (for several weeks) to treat the lesion himself with an OTC topical ointment that contains bacitracin. Unfortunately, this didn't help; the lesion just continued to enlarge and look more serious. Now, it has finally gotten ugly enough to scare the executive into taking a little time off to seek professional advice.

On examination, the rather impressive lesion is found to be about 4 cm in diameter. It is on the left leg, near the knee, and is ulcerated, with a surrounding area of fibrosis, edema, and erythema. Despite the ugly appearance of the lesion, it is not overly painful. The man says that, when he first noticed it about 2 months ago, it was only about 5 mm in diameter and looked a little like a common boil.

The physician asks the man if he participated in any extended outdoor activities during the past six months. The man says that, about four months ago, he took a rare weekend off in order to hike in a wilderness area with a group of his co-workers. The group hiked along a relatively unspoiled tributary of the Mississippi River in Louisiana for two days and then enjoyed a fine dinner in New Orleans. The man feels that, except for the sore on his leg, he has been in good health. However, he admits that he doesn't take vitamins, watch what he eats, exercise, or make any other significant effort to take care of himself. His job really is extremely stressful. He doesn't smoke, but he sometimes drinks pretty heavily after he gets home in the evening.

Question 7.1: What is your diagnosis?

Question 7.2: What is the causative agent?

Question 7.3: How is the diagnosis confirmed?

Question 7.4: How did the patient become infected?

Question 7.5: Where is this disease endemic?

Question 7.6: How does the disease progress?

Question 7.7: What could happen if this patient were immunocompromised?

Question 7.8: How should you treat this case?

CASE 8

A 21-year-old male college student presents with superficial lesions on his trunk. The man recently returned from a summer job working as a counselor in a summer camp for underprivileged kids from inner-city neighborhoods. Many of the kids come from relatively poor families that do not practice good personal hygiene. As a result, many of them have minor skin and scalp problems. The man's duties at the camp included supervision of swimming classes and other outdoor activities. He also served as the resident supervisor in one of the cabins in which the kids slept and showered.

On examination, the man is found to have seven distinctive, roughly circular skin lesions on his body. The lesions range from 2 to 8 cm in diameter and are have well demarked edges. The edges of the lesions are highly inflamed, where there is little or no inflammation in the center of the larger lesions. The borders of the lesions are scaly, slightly raised, and noticeable reddened. The centers of some lesions are hypopigmented. The man indicates that the lesions first developed about three weeks earlier and have been enlarging steadily sine that time. They are quite itchy, but not overtly painful. The lesions appear to be pretty superficial, affectng only the cutaneous layers of the skin. The man's vital signs are normal, and there are no other remarkable physical findings.

Question 8.1: What is your diagnosis?

Question 8.2: What is the causative agent?

Question 8.3: How is the diagnosis confirmed?

Question 8.4: How typical are the patient's lesions?

Question 8.5: How was the man infected?

Question 8.6: How common is this disease?

Question 8.7: Is this disease dangerous?

Question 8.8: How should you treat this case?