Abstract: 15 y/o girl with rash and joint pain for 4 weeks
History: 15 y/o girl reported having a pruritic rash on the extensor surface of her hands and wrists that started 4 weeks ago and seemed to be getting worse. She also noticed morning stiffness that lasted 1 hour and joint pain in her wrists and hands. She was started on fluoxetine for depression almost 4 months prior and had a URI 2 months prior. She has been healthy since then.
On review of symptoms pt denied constitutional symptoms, rash/pain elsewhere or GI symptoms. She denied contact with new materials/chemicals.
Pt was given ibuprofen and then naproxen without improvement. She was then given a 10-day prednisone taper starting at 60 mg without any improvement.
PMH included allergic rhinitis, depression and hearing loss. Family history revealed maternal grandfather with psoriasis, no history of autoimmune or joint problems.
O/E: Afebrile. Examination of skin revealed abrasion-like plaques on the extensor surfaces of the wrists and MCP joints. These plaques initially had an erythematous base which later became hyperpigmented. There was crusting and dry skin but no exudate or ulcerations. No nail findings. There were no skin findings elsewhere. The hands were slightly edematous but no synovial thickening or effusions were detected. The wrist, MCP and some PIP joints were tender to palpation bilaterally. The remainder of the MSK exam was unremarkable.
Clinical Photo(s): Taken at pt's 3rd visit, 4 wks after her rash first appeared
Lab: CBC unremarkable except for Eos of 8%. ESR 22. CRP, RF, ANA were negative.
Histopathology: pending
Diagnosis or DDx: ? JRA, psoriatic arthritis, drug rxn, pseudo-PCT, post-viral exanthem...
Questions: Any more ideas? Does lack of response to prednisone change the DDx/plan? (Pt was referred to rheumatology) Thanks.
Reason(s) Presented: Interest
References:
Presented by: Stephanie Chu MS4
2 comments:
This is a well-presented case. Clinically the eruption looks like a dermatitis, but the symmetry would be unusual. In the differential diagnosis, I would include dermatomyositis. Some cases only have skin involvement (amypathic DM) - but it still might be worthwhile to do a creatine kinase. If DM, the skin biopsy would be helpful -- but it would need to be seen by a dermatopathologist.
Interesting case and very clear images. The skin lesions appeared eczematous - rough symmetrical patches on the wrist and dorsum of MCP joints with erythema, papules and excoriations. The raised eosinophil counts may support diagnosis of endogenous eczema. Dermatomyositis is a good thought but would expect lesions to be more vasculitic, purpuric or papular and less pruritic. Try topical corticosteroids and perhaps avoid the various trigger factors. I am not sure if the polyarthralgia is related to the skin lesions - all her serology is negative anyway. A negative CPK would be reassuring too. The polyarthralgia may be post viral or drug related. I would watch and monitor her progress.
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