If you prefer to view this article in PDF form, click here.

Erica Lundsten works in trauma surgery at Sentara Norfolk General Hospital, Norfolk, Va. Maureen Morgan and Richard Andrews practice at the Bayview Community Health Center, Cheriton, Va. The authors have indicated no relationships to disclose relating to the content of this article. Erich Fogg is Assistant Professor in and Program Director of the Physician Assistant Program at the College of Health Professions, University of New England, Portland, Me.

CASE

The patient is a 23-year-old Hispanic migrant fieldworker who presents with a painful rash on his limbs, trunk, and face. The patient states the rash began 3 years ago on his lower extremities and spread proximally. A topical cream consisting of betamethasone, clotrimazole, and gentamicin is not providing any relief. A 2-day history of feeling feverish and increasing diffuse pain and swelling of his lower extremities has affected his ability to work. The rash is not present in any family members or coworkers. The history of exposure to streptococci is unknown.

Physical examination The patient is afebrile, and vital signs are stable with the exception of hypotension (BP, 88/60 mm Hg). He is alert and oriented but seems anxious. His skin has multiple erythematous, dry, scaling patches covering his whole body except the genitals and palmar and plantar surfaces. His abdomen has patches of thick, dry, brown confluent plaques and areas that are moist, with desquamation, erythema, and tenderness (see Figure 1). There are also confluent, blanching erythematous plaques on his back, torso, and chest. The patient has 1+ edema of the ankles and feet. Otherwise, physical examination findings are normal.

Laboratory results CBC results include abnormal hemoglobin (11.6 g/dL) and hematocrit (34.2%) with normocytic, normochromic indices and neutrophilia at 81%. Results of an anemia profile are serum iron, 24 µg/dL and iron saturation, 9%. The ferritin value is normal at 56 ng/mL. B12 and folate levels are normal. A blood culture shows no growth after 5 days. Results of a basic metabolic panel are normal except for blood glucose (194 mg/dL) and AST level (42 IU/L). Glycosylated hemoglobin is normal.

WHAT IS YOUR WORKING DIAGNOSIS?

DISCUSSION

Guttate psoriasis, the correct diagnosis, affects all races and both sexes equally, with a typical age of onset younger than 30 years. Usually diagnosed by skin appearance, it is characterized by diffuse, teardrop-shaped, silvery scaling patches overlying an erythematous base. While psoriasis is a common condition, the guttate form is relatively rare. Believed to be an inherited disorder resulting from an inflammatory response to infection, typically with group A beta-hemolytic streptococci, psoriasis can affect any part of the skin. A bacterial throat culture and elevated levels of antibodies to streptolysin O, hyaluronidase, and deoxyribonuclease B may help confirm the diagnosis.¹

Guttate psoriasis may disappear on its own in a few weeks, so treatment should be individualized. Application of emollients (petroleum jelly plus water) and topical corticosteroids may benefit localized eruptions.

This patient also had an underlying secondary impetigo, which is typically caused by streptococcal or staphylococcal infection. Impetigo may be treated with gentle debridement and application of topical mupirocin ointment to the affected area. For more extensive infection, systemic antibiotics should be used. Care should be taken to avoid infecting others.²

Comment We administered 1 L of lactated Ringer’s solution, and the patient’s BP improved to 110/82 mm Hg. He was given ceftriaxone (1 g) and methylprednisolone sodium succinate (125 mg) IV at the clinic. We sent him home with a prescription for methylprednisolone (Medrol Dose Pack) to treat the psoriasis and 500 mg dicloxacillin to treat the secondary diffuse impetigo. A dermatologist agreed with the diagnosis and recommended salt water baths twice daily and etanercept, 50 mg twice weekly for 12 weeks and then 50 mg weekly for maintenance. The dermatologist also recommended weekly methotrexate injections and laboratory tests to monitor response to treatment. We added triamcinolone and an emollient as well. The patient began treatment with us but later moved and was lost to follow-up.

REFERENCES

1. 1. Baron E, Taylor CR. Psoriasis, guttate. eMedicine. Available at: www.emedicine.

2. Tierney LM Jr, McPhee SJ, Papadakis MA. Current Medical Diagnosis and Treatment. New York, NY: Lange Medical Books; 2005.

© 2007 Haymarket Media, Inc. and the American Academy of Physician Assistants. All rights reserved.
Use of jaapa.com subject to License agreement. Please read our Disclaimer and Privacy policy.