Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers
Chat recap of the #ClinicalPearls #VirtualMorningReport

June 5th Day 65: clinicalproblemsolving.com/morning-report…
w/ Brian Rosenberg @DxRxEdu @rabihmgeha

Teaching points clinicalproblemsolving.com/wp-content/upl…

Before we start, there were some great reflection from @RezidentMD and @AnandJag1

Knowing when we don’t know let’s us start learning, whether about pathophysiology or about social determinants like racism.

A recommended read: from Carlos Estrada: CHAPTER 42 The Traumatic Impact of Racism and Discrimination on
Young People and How to Talk About It
shop.aap.org/reaching-teens…

Let's start with a problem representation:

A 68 y/o F p/w an itchy arthralgias, an itchy red rash to palms/legs, and abd pain was found to have large palpable purpura in her LE, colitis, proteinuria, and renal insufficiency.

Rash over the lower limbs, think vascular

Lower limbs make me think erythema nodosum first and foremost

Rash - important to know the type (macular, papular, vesicular etc), areas involved, associated systemic symptoms

A symmetrical rash seems like an inside job

Pruritus is so common in rashes. The only thing it triggers for me is "inflammatory" from any cause.

Plus want to know other systemic symptoms (e.g. fever), joint symptoms, lung pathology, etc.

Pruritis is not necessarily inflammatory.biliary path can cause pruritis too!

Biliary pathology pruritus shouldn't cause rash. The pruritus is 2/2 bile salt deposition ncbi.nlm.nih.gov/books/NBK20092…

Bile acids have been reported to trigger local “itch” when injected in nml volunteers

Rocky mountain spotted fever starts on ankles and wrists

There is an entity called papular purpura stocking and glove syndrome which is associated with parvo among others. usually seen in younger pts though. ncbi.nlm.nih.gov/pmc/articles/P…

Arsenic poisoning would cause a rash, (hyperpigmentation) in areas that are not exposed to sunlight,dermnetnz.org/topics/chronic…

Pruritus without skin findings - should evaluate for underlying systemic causes - CMP for liver/renal disease, thyroid, HIV, CBC diff for lymphoma + PV

If the above negative - consider HCTZ, CCB, opiates, NSAIDs

Drug-induced hypersensitivity syndrome (DIHS) the newer name for DRESS, ncbi.nlm.nih.gov/pmc/articles/P…

Sudden onset umbilicated lesions (molluscum) could suggest uncontrolled HIV.

Petechial rashes don’t typically cause itching

What about Henoch-Schonlein purpura (HSP), I know she's too old for it, but other than that it could be

It’s not anchoring if you get it right

Curbsides has a great episode on an approach to rash, thecurbsiders.com/podcast/161-ra…

Scurvy would classically have a perifollicular hemorrhage.

Listen to this @BedsideRounds w/ @AdamRodmanMD episode on #Scurvy. bedside-rounds.org/tag/scurvy/

With an itchy acute rash, its generally drug induced

Rubella can cause arthritis + rash

How often is she taking the naproxen? NSAIDs and Acute interstitial nephritis jumps to mind too

Perimbilical rash..is this strongyloides? The periumbilical thumbprint parasitic purpura (PTPP) sign of strongyloidiasis is seen in the more advanced stages. ncbi.nlm.nih.gov/pmc/articles/P…

Palmar rash - syphilis, coxsackie, rickettsial

Non-infectious causes of palmoplantar rashes, what to consider. ncbi.nlm.nih.gov/pmc/articles/P…

Differential diagnosis of a palmar and plantar rash, bmj.com/content/347/bm…

Rash with ulceration: Pemphigus vulgaris, bullous pemphigoid?

Lofgren syndrome with arthralgia, erythema nodosum, hilar lymphadenopathy (sarcoid variant)

The dusky center reminds me of erythema multiforme

rat-bite 🐀 fever can also cause palmar rash remedypublications.com/open-access/sk…

Nikolski - if thinking pemphigus, learned 2days ago that the advice is NOT TO elicit the sign with dermatology on board. It can trigger a massive reaction

Also interested if ever tested for hep c thinking about cryo

A secondary syphilis case, aafp.org/afp/1999/0301/… review

Want to know if this edema is chronic for her. It might give us a suggestion before the labs/workup to things like nephrotic syndrome/cirrhosis/heart failure/hypoalbuminemia that we could tie together with the rash

all samll and middle vessel vasculitis are fair game

would love to see UA for proteinuria. IgA vasculitis can cause palpable rash

PAN, Henoch-Shonlein, cryo, ANCA+,, drug-induced, secondary to connective tissue disease ou chronic infection

Labs: ua, urine.protein, complements, Rf, rpr, anca, hepatitis panel, hiv, and culture.

DDx for palms/soles rash: Infections like coxsackievirus, syphilis, RMSF, scabies, & tinea;

Inflammatory dermatoses such
as psoriasis, eczema, erythema multiforme, and mycosis fungoides, and drug eruptions

epocrates.com/sites/default/…

Isn’t HSP rare at this age?

About 1% of Crohn's patients can have amyloidosis 2/2 chronic inflammation

PAN would also be on ddx. but they usually have renal aneurysms

Having trouble fitting in the findings of colitis from CT to fit my illness scripts for glomerulopathies

Unless hickums dictum is at play

This could be a Dermatologic Manifestations of IBD like UC. ncbi.nlm.nih.gov/pmc/articles/P…

Hard to tie in the glomerulonephropathy though unless they are on IBD drugs many of which can cause AIN (sulfasalazine comes to mind)

You can also get eosinophilic vasculitis secondary to Whipple's disease, ncbi.nlm.nih.gov/pmc/articles/P….

A schema for intrarenal AKI, clinicalproblemsolving.com/dx-schema-intr…

Chat wants vasculitis

Hep b /c associated with pan

HSP is most likely given the schema from the normal C3/C4

HSP common in kids and is assoc with intussusception in kiddos due to hematomas as leadpoints

Vasculitis is always humbling

HSP in adults is not the normal.

The clinical tetrad of non-thrombocytopenic palpable purpura, abdominal pain, arthritis and renal involvement

HSP review and case report, hindawi.com/journals/grp/2…

ncbi.nlm.nih.gov/pmc/articles/P…

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