Soldier With Widespread Dermatologic Outbreak - Page #1

Author: Jacob Bright, DO Candidate
Co Author #1: Caitlyn Rerucha, MD Womack Army Medical Center – Family Medicine Residency Fort Bragg, NC
Co Author #2: Caitlyn Rerucha, MD Womack Army Medical Center – Family Medicine Residency Fort Bragg, NC
Co Author #3: Caitlyn Rerucha, MD Womack Army Medical Center – Family Medicine Residency Fort Bragg, NC
Editor: John Wick, MD

Patient Presentation:
A 26 y/o male soldier presented to the Emergency Department with worsening, painful, weeping plaques about dorsal feet Case Photo #2 with recent progression of rash to include his trunk and upper extremities Case Photo #4 . He returned from a twelve-month deployment to Afghanistan six weeks prior. During the course of his deployment there was a slow worsening in dorsal foot rash with prompt worsening over several days.

He denied any history of cold sores, oral or genital ulcers, dysuria, photophobia, or skin tenderness. He also denied ever having had any arthralgias, fevers, chills, or malaise.

During the course of his deployment in Afghanistan he was treated at an aid station for tinea pedis with topical naftin (naftifine) & lamisil (terbinafine) and later oral diflucan (fluconazole) with limited improvement in his symptoms.

Near the end of his deployment he underwent a trial of treatment for possible boot dermatitis with a
prednisone burst and mupirocin (bactroban).

Past Medical History – non-contributory
No history of atopy, psoriasis or autoimmune disease.

Past Surgical History - significant for a Lisfranc fracture repaired with internal titanium fixation (2008).

Medications - previous oral medications included doxycycline and primaquine after returning from deployment with last dose six weeks prior to presentation.

Allergies - no known history of drug or food allergies.

Initial TX upon presentation to Emergency Department:

120 mg IM methylprednisolone (Solu-medrol) prior to examination by the Family Medicine Inpatient Team / Dermatology

Wound, viral cultures, Tzanck prep & KOH were performed.

Broad-spectrum empiric antibiotics were initiated for coverage against both gram positive and gram negative organisms as well as possible herpetic overlay with IV Clindamycin, IV Zosyn & IV Acyclovir.

He ultimately was transitioned to oral antibiotics (levaquin, clindamycin) and oral valtrex (valacyclovir) as his clinical picture improved during the hospital course.

Physical Exam:
General Appearance:
AAOx3 – appeared uncomfortable but non-toxic and in no acute distress

General Medical Exam:
HEENT, cardiovascular system, pulmonary system and abdominal exam – unremarkable

Exam unchanged throughout hospital course

Full Body Skin Exam (at presentation):
Well-demarcated, symmetric involvement of dorsal feet Case Photo #2 :
Brightly erythematous, macerated plaques with discrete and confluent overlying erosions. There were several areas ‘punched out’ in appearance and clear, honey-colored crusting was present. Case Photo #5

Web-spaces of feet:
Maceration, deep-seated vesicles, honey-colored crusting. The plantar surfaces were never involved.

Numerous tense-walled deep seated papules, papulovesicules about dorsal and lateral surfaces of fingers Case Photo #6 .

Discrete and confluent erythematous papules and plaques. Some of these also had mild overlying scaling

Pertinent negatives from full body skin exam:
There was never any mucosal involvement or skin tenderness/erosions (aside from feet). There were no stigmata to suggest psoriasis at time of initial presentation, to include examination of: scalp, extensor surfaces (elbow/knees), and nails, groin & buttocks.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.

NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.

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