Spot Diagnosis # 5

A 70 years old male presented with earache deep inside the left ear radiating to pinna. On examination, his left external canal and pinna showed vesicular rashes with drooping left side of the mouth.  What is your spot diagnosis?

Answer:
The diagnosis is Ramsay Hunt Syndrome (RHS). It is a reactivation syndrome of herpes zoster virus in an L-shaped ganglion of facial nerve named  as geniculate ganglion, present in facial canal. RHS occurs when herpes zoster virus infects facial nerve and presents with painful shingle rash with fluid filled vesicles seen on, in or around the single ear. It may present with ear pain, hearing loss, ringing of ear, difficulty in closing the eye on the affected side as well as vertigo, change in taste and facial paralysis. All the signs and symptom described in the scenario above support the diagnosis of Ramsay Hunt Syndrome or herpes zoster oticus.

Spot Diagnosis # 4

Keywords: Earache, Vesicular rash, Drooping mouth, Ramsay Hunt Syndrome or herpes zoster oticus

Spot Diagnosis # 4

A 25 years old boy, a treated case of tuberculosis presents with shortness of breath and painful tense, distended abdomen (image of the abdomen is shown below). Echocardiography shows a thin pericadial effusion around the heart. Ultrasound shows splenomegaly. What is your spot diagnosis?

Tense distended abdomen

Please write your spot diagnosis below in the "comments section". The answer will be given after a week!

Spot Diagnosis # 3

Keywords: Tuberculosis, Thin pericardial effucion, Distended abdomen

Spot Diagnosis # 3

A 90 years old emaciated female with the given image of reddened palmar aspect of her hands. She is known case of metastatic hepatic cancer. She has not applied and colour or mehndi. What is your spot diagnosis?

Palmar redness

Answer:

Diagnosis: Palmar Erythema (PE) due to hepatic CA

What is palmar erythema?

Palmar erythema is a non-specific condition where palms of the hands become red, especially at thenar (at the base of thumb) and hypothenar (at the base of little finger) eminences. Palmar erythema may be normal, may be physiological or may be pathological. It may be primary palmar erythema (e.g. pregnancy, heredity and idiopathic) or secondary palmar erythema (various conditions/diseases).

What causes palmar erythema?

The exact cause of palmar erythema is yet not known. However, some experts are in view that high levels of estrogen in the blood cause palmar erythema as this hormone has been seen raised in cirrhosis of liver and during the pregnancy. It is thought that estrogen increases vascularity, leading to redness of palms. Redness of palms in palmar erythema varies person to person and may extend to the fingers and nail beds.

Which conditions have palmar erythema?

A lot of conditions have palmar erythema as a sign. The following conditions/diseases show PE:

1. Pregnancy- PE in pregnancy is a type of primary PE and is shown by about 30% of the pregnant women.
2. Chronic liver disease- About 23% patients with CLD show secondary PE.
3. Portal hypertension
4. Polycythemia
5. Rheumatoid arthritis- More than 60% patients with RA show secondary PE.
6. Thyrotoxicosis- About 18% patients with thyrotoxicosis show secondary PE.
7. Eczema or psoriasis
8. Drug-induced- Drugs such as amiodarone, gemfibrozil, cholestyramine, topiramate and albuterol also cause secondary PE as a side effect. 
9. Metastatic and primary brain neoplasms- Increased angiogenic factors and estrogens levels in the patients with metastatic and primary brain neoplasms show secondary PE.
10. Smoking- An environmental cause of PE
11. Chronic mercury poisoning- An environmental cause of PE

What is the treatment of palmar erythema?

There is no treatment of palmar erythema except treating the cause. Drug-induced PE can be abolished by discontinuing the same drug.

Spot Diagnosis # 2

Keywords: Palmar erythema, PE, Pregnancy, CLD, RA, Rheumatoid arthritis, Hepatic cancer, Metasatic liver cancer, CA liver, Red hands, Palmar redness

Spot Diagnosis # 2

A 65 years old male patient presents with red, hot and painful right leg with some pus-filled blisters (as shown in the image below). The patient is known case of liver cirrhosis. What is your spot diagnosis?

A 60 years old male with red, hot and painful leg

Answer:

Diagnosis: Cellulitis

What is cellulitis?

Cellulitis is a serious and spreading infection of skin and underlying tissue. This infection can occur anywhere in the body; however, skin of the lower limbs is affected most of the times.

What causes cellulitis?

Cellulitis is a bacterial infection. Most often staphylococcus and streptococcus are the culprits. Other bacteria include methicillin-resistant Staph aureus, Hemophilus influenzae, Pneumococcus, and Clostridium.

What are the risk factors of cellulitis?

Cuts and cracks, insect bites, surgical incisions, weakened immune system, eczema and athlete’s foot, IV drug use and abuse, previous history of cellulitis, and chronic or debilitating disease, especially diabetes, liver cirrhosis and renal failure.

What are the sign and symptoms of cellulitis?

The patient with cellulitis presents with pain, redness and swelling of the affected area. On examination, the affected area is observed swollen, red, hot, tender and with tight glossy appearance. The patient is febrile and the skin may have sores.

What is the treatment of cellulitis? 
Depending upon the severity of the infection, oral or intravenous antibiotics are given. Penicillin is the drug of choice for cellulitis. Analgesics are used to relieve from pain. Elevation and compression dressing of the affected area are mandatory to reduce edema. Amclav 1g (Amoxicillin 875mg, Clavulanic acid 125mg) orally, twice a day, is used as adult dose in cellulitis. Amclav 1.2g IV twice a day is also used in severe cellulitis.

What to do to prevent cellulitis? 
You can prevent cellulitis by keeping the skin moist (to avoid skin cracks), treating the skin infections promptly, wearing protective covering while working and inspecting the skin on daily basis.

Spot Diagnosis# 1

Keywords: Cellulitis, Cellulits treatment, Signs and Symptoms, Red hot leg, Painful, Pus-filled blisters

Spot Diagnosis # 1

A 4-5 years old male child presented with the black spots on his both legs along with bleeding from oral mucosa (as shown in the images below). His hemoglobin level was found to be 12 gm/dl, total leukocyte count 7400/cumm and platelets 51000/cumm. What is your spot diagnosis?

Answer:

Diagnosis: Idiopathic thrombocytic purpura (ITP)

What is ITP?
ITP is a blood disorder where platelets (a kind of blood cells) are destroyed autoimmunically by the spleen.
What causes ITP?
ITP is caused by antiplatelet autoantibodies, leading to destruction of platelets through the process of phagocytosis.
What are the risk factors of ITP?
Usually it is seen that viral infections precipitate the development of ITP. In its acute form, ITP occurs after two weeks of infection with self-limiting bruises, petechiae and purpura. In its chronic form, it runs an indefinite course of signs and symptoms like bleeding, purpura, bleeding from nose or heavy menstruation.
What are signs and symptoms of ITP?
ITP may present as bleeding from mucus membranes like oral mucosa and tiny hemorrhages or black spots on the body.
Does ITP cause splenomegaly?
Bear in mind, in ITP, there is no splenomegaly.
What tests are carried out in ITP?
Bone marrow examination shows increased number of megakaryocytes in marrow. Antiplatelet autoantibodies may also be seen in the blood. Mild disease may not need any treatment.
How to treat ITP?
If the condition is symptomatic or platelets are below 20000/L, prednisolone 1mg/kg/day should be started (and reduce the dose after remission). The target of the therapy is to keep platelets above 30000/L.
If ITP relapses?
If ITP relapses, splenectomy results in 80% cure. Immunosupression (azathioprine or cyclophosphamide) may be started if the management still fails.
Should we transfuse platelets?
Do not transfuse platelets.
What to do during pregnancy?
Intravenous immunoglobulins may raise platelet count temporarily in conditions such as surgery and pregnancy.

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Keywords: ITP, Diagnosis, Splenomegaly, Haematology, Platelet disorder, Low platelets