Person:

Mostaghimi, Arash

Pyogenic granuloma, also known as lobular capillary hemangioma, is a common benign vascular proliferative lesion that can present at any age on the skin or mucous membranes. Most lesions do not exceed 2 cm, but there are a handful of giant cutaneous pyogenic granulomas that have been reported, often in individuals with underlying immune dysfunction. Here, we report the first giant pyogenic granuloma in a patient with a hematological malignancy, chronic lymphocytic leukemia.

Cutaneous paraneoplastic syndromes comprise a broad spectrum of cutaneous reactions to an underlying malignancy. These dermatoses are not the result of metastatic spread to the skin, but rather a reaction to the presence of malignancy. Cutaneous paraneoplastic syndromes often precede the identification of a malignancy. We describe the case of a 79-year-old man with a six-month history of recalcitrant treatment- resistant dermatitis. A complete blood count test performed at the time of initial presentation was normal. The patient ultimately presented with erythroderma and was diagnosed with acute myeloid leukemia (AML). The evolution of the dermatitis to erythroderma coincided with the clinical presentation of AML, and was therefore considered to be a paraneoplastic syndrome. The patient decided against therapy and died seven weeks after diagnosis. Physicians should consider a cutaneous paraneoplastic syndrome when faced with dynamic recalcitrant dermatoses that are difficult to treat and decide on laboratory testing accordingly. Patients should be evaluated regularly for two to three years after initial diagnosis with a physical exam and review of systems to monitor for signs and symptoms of malignancy.

Background: The increased use of social media, cloud computing, and mobile devices has led to the emergence of guidelines and novel teaching efforts to guide students toward the appropriate use of technology. Despite this, violations of professional conduct are common. Objective: We sought to explore professional behaviors specific to appropriate use of technology by looking at changes in third-year medical students’ attitudes and behaviors at the beginning and conclusion of their clinical clerkships. Methods: After formal teaching about digital professionalism, we administered a survey to medical students that described 35 technology-related behaviors and queried students about professionalism of the behavior (on a 5-point Likert scale), observation of others engaging in the behavior (yes or no), as well as personal participation in the behavior (yes or no). Students were resurveyed at the end of the academic year. Results: Over the year, perceptions of what is considered acceptable behavior regarding privacy, data security, communications, and social media boundaries changed, despite formal teaching sessions to reinforce professional behavior. Furthermore, medical students who observed unprofessional behaviors were more likely to participate in such behaviors. Conclusions: Although technology is a useful tool to enhance teaching and learning, our results reflect an erosion of professionalism related to information security that occurred despite medical school and hospital-based teaching sessions to promote digital professionalism. True alteration of trainee behavior will require a cultural shift that includes continual education, better role models, and frequent reminders for faculty, house staff, students, and staff.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug reaction characterized by erythema over the buttocks, thighs, groin, and flexural regions most commonly associated with the use of beta-lactam antibiotics. Although the exact pathophysiology of this disease remains unknown, it is theorized to be the result of a delayed hypersensitivity response presenting as a cutaneous eruption days to weeks after exposure to the drug. The treatment involves discontinuation of the suspected medication, symptomatic control of pruritus, and topical steroid therapy. A 51-year-old woman with homocystinuria and fibromyalgia was admitted with fevers, pancytopenia (later diagnosed to be acute myelogenous leukemia), and a targetoid cutaneous eruption in the setting of a recent tick bite. She was subsequently noted to have symmetric, pruritic, erythematous papules over the lateral neck, retroauricular regions, lateral aspects of the inframammary regions, medial upper arms, axillae, and the lower abdomen two weeks after starting doxycycline. Considering the morphology, distribution, and intense pruritis associated with the eruption, a diagnosis of SDRIFE was made. Doxycycline discontinuation along with topical steroid therapy resulted in the resolution of the eruption and pruritus. Given the widespread use of doxycycline, clinicians should be aware of this possible side effect.

Merkel cell carcinoma (MCC) is an aggressive skin cancer with a mortality of 33%. Advanced disease at diagnosis is a poor prognostic factor, suggesting that earlier detection may improve outcome. No systematic analysis has been published to define the clinical features that are characteristic of MCC.

Objective

To define the clinical characteristics present at diagnosis in order to identify features that may aid clinicians in recognizing MCC.

Methods

Cohort study of 195 patients diagnosed with MCC between 1980 and 2007. Data were collected prospectively in the majority of cases, and medical records were reviewed.

Results

An important finding was that 88% of MCCs were asymptomatic (nontender) despite rapid growth in the prior 3 months (63% of lesions) and being red or pink (56%). A majority of MCC lesions (56%) were presumed to be benign, with a cyst/acneiform lesion being the single most common diagnosis (32%) given at biopsy. The median delay from lesion appearance to biopsy was 3 months (range 1–54 months), and median tumor diameter was 1.8 cm. Similar to prior studies, 81% of primary MCCs occurred on UV-exposed sites, and our cohort was elderly (90% over age 50), predominantly Caucasian (98%), and often profoundly immune suppressed (7.8%). An additional novel finding was that chronic lymphocytic leukemia was more than 30-fold over-represented among MCC patients.

Limitations

The study was limited to patients seen at a tertiary care center. Complete clinical data could not be obtained on all patients. This study could not assess the specificity of the clinical characteristics of MCC.

Conclusions

This study is the first to define clinical features that may serve as clues in the diagnosis of MCC. The most significant features can be summarized in an acronym: AEIOU -Asymptomatic/lack of tenderness, Expanding rapidly, Immune suppression, Older than age 50, and UV-exposed site on a person with fair skin. In our series, 89% of primary MCCs had three or more of these findings. Although MCC is uncommon, when present in combination, these features may indicate a concerning process that would warrant biopsy. In particular, a lesion that is red and expanding rapidly yet asymptomatic should be of concern.

Herein we present a case of a patient with systemic lupus erythematosus (SLE) and a sterile empyematous pleural effusion, a complication not generally associated with SLE. A discussion of the diagnostic and treatment dilemmas follows the case presentation.

Dermatology residents perform consults on hospitalized patients, but are often limited in their ability to follow-up with these patients after discharge, leading to inadequate follow-up and understanding of post-discharge transitions of care. In 2013, a discharge continuity clinic (DCC) staffed by the inpatient consult dermatology resident and attending dermatologist was established at one of the four adult hospital sites residents rotate through in the Harvard Combined Dermatology Residency Program. Resident perceptions about the DCC and their educational experience on inpatient consult rotations with a DCC and without a DCC were obtained using a cross-sectional survey instrument in June 2016. Self-reported data from a multi-year cohort of dermatology residents (n = 14 of 20, 70% response rate) reveals that the DCC enabled resident autonomy and resident satisfaction in care of their patients,insight into the disease-related challenges and the broader social context during transitions of care from inpatient to outpatient settings, and more enriching learning experiences than inpatient consult rotations without a DCC. Dermatology residents self-report participation in an inpatient consult rotation with aDCC supports their autonomy and achievement of post-discharge transitions-of-care competencies.

To the Editor We applaud the evaluation by Guy and colleagues of costs for sunburn-associated visits to US emergency departments. Their analysis was performed using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) primary and secondary billing codes for sunburn (692.71, 692.76, and 692.77) in discharge records from the National Emergency Department Sample database.

Sunburn led to an estimated 33 826 visits to US emergency departments (EDs) in 2013, resulting in a cost of $11.2 million. Despite this burden, little is known about the features of patients utilizing the ED or urgent care clinic (UCC) for treatment of sunburn. Characterizing this patient population may help guide efforts of prevention, utilization reduction, and transition of care to lower cost settings. In this study we examined the demographics and characteristics of patients seen at the ED or UCC for sunburn treatment at 2 major hospitals over a 15-year period.

Question What is the effect of vaccination on emergency department utilization for herpes zoster?

Findings In this population-based, descriptive epidemiologic study of more than 1.3 million herpes zoster–related emergency department visits from 2006 through 2013, the overall rate of visits rose by 8.3%, driven by an increased number of visits by patients aged 20 to 59 years; populations recommended for vaccination (aged <20 and ≥60 years) demonstrated a decrease in utilization. Herpes zoster annual incidence rates fell after the recommended use of the herpes zoster vaccine in 2008 in patients 60 years or older.

Meaning Vaccination may be associated with a reduction of emergency department utilization for herpes zoster.