Patient is a 21 year old female in junior year of college. She has no chronic medical conditions and takes no medications on a regular basis. Her only surgical history is tonsillectomy as a toddler. She is being seen today for complaints of "acne." She was seen previously at her campus health center and was given a script for t-stat pads (erythromycin topical), which she has been using for two weeks and feels her condition has only worsened. She has also tried over the counter benzoyl peroxide face washes BID without aid. It is now winter break and she is home for three weeks from college. She states she feels tired following a busy exam week, but otherwise feels well. She would like her acne resolved before returning to campus!
Vital signs are normal. BMI 24 with a 5 pound weight loss noted since last visit 1 year ago. She attributes that to making healthier choices in campus dining. Physical exam is notable for scattered pustules ranging in size from 1-2cm across cheeks, forehead, chin, and shoulders. Some are erythemic, some white. Some have scabs, others are intact and fluid filled. None are actively draining.
What at should be the next steps for this patient?
Patient was referred to see derm. Thankfully, they had a cancellation and were able to get her in the next day. There a total skin exam was done. The lesions on her face and arms were there as previously described. Also noted were petechiae on her bilateral shins and a bruised area on her lower back, deep purple in color, approximately 4 by 3 cm. She states that she cannot remember where she got this bruise, and denies injury. She adamantly states that she feels safe both in her home and on campus environments.
A full review of systems is done and the patient admits that she has been feeling tired the last month to six weeks, has been having mystery bruises periodically, and has been having chills and body aches on and off the last three weeks or so, which she equates to a cold she can't get rid of. She states she hadn't previously mentioned these symptoms since so many of her classmates have had colds and flus living in the dorms during the chilly late fall months and not sleeping enough during stressful exam season, she figured it was normal.
A skin biopsy is done of areas on her face and arm. A culture is also done.
Stat labs are sent for a CBC with diff, PT/INR, PTT, Fibrinogen, Mg, Phos, LDH, and uric acid level, along with a blood culture.
She goes home to wait for the test results. Meanwhile, the dermatologist is looking at the slides himself for the rare presentation of the systemic disease he fears she has, hoping he won't have to give her that news tomorrow.
Not sure how to get a culture when antibiotics are already in use, but suspect MRSA, etc. Consider an added allergic response to one of the meds. Do a careful diet analysis and look for vitamin A deficiency. Consider zinc level to rule out that as a cause. Launder towels, pillow cases, etc. with hot water and bleach, or if colored, consider ironing them to kill bacteria.
I agree with whoever said sarcoidosis. She needs a detailed family health history taken, as well as potential exposures (where she works, lives, etc.). She also says several of her classmates have been sick, which could have initiated the immune response.
And now I have to Google sarcoidosis...I thought that was a lung disease?
Lev, MSN, RN, NP
4 Articles; 2,805 Posts
Shingles was my thought too...but that wouldn't explain the weight loss...I'm starting to think this is autoimmune.