Eczema herpeticum: making the diagnosis in the emergency department.

Eczema herpeticum (EH), a form of Kaposi's varicelliform eruption, is the dissemination of herpes simplex virus in the setting of preexisting eczema. We discuss the case of an 18-year-old woman with underlying atopic dermatitis (AD) who presented to an Emergency Department complaining of malaise, fever, and a spreading, burning, vesiculopapular facial rash. She was treated for both presumed impetigo and a flare of her underlying AD with cephalexin, bacitracin ointment, topical steroids, and diphenhydramine. Her condition worsened, and she was seen 3 days later by her primary care physician, who recognized the superimposition of a herpetic infection on her underlying AD and revised the diagnosis to EH. An oral regimen of acyclovir led to prompt resolution of the patient's rash and symptoms. Recognition of EH in the acute care setting is essential for the provision of timely and specific treatment and to avoid the serious sequelae of this condition.

An update on the diagnosis and treatment of early Lyme disease: "focusing on the bull's eye, you may miss the mark".

To confidently diagnose and treat Lyme disease, the clinician must first understand the natural history of this disease, especially its protean early manifestations. Emergency physicians, primary care physicians, and other providers need to be vigilant in terms of the timely recognition of erythema migrans (EM), the unique marker of early localized stage 1 disease. The classic EM, originally described as a slowly expanding bull's eye lesion, is now recognized to be present in only the minority of cases (9%); the dominant morphologic lesion of EM is now recognized to be the diffusely homogenous red plaque or patch, which occurs in over 50% of cases. This update will define the current morphologic features of early Lyme disease, the indication for serologic studies, and the most recent treatment guidelines, including therapeutic pitfalls.

Development of unilateral cervical and supraclavicular lymphadenopathy after human papilloma virus vaccination.

A 26-year-old woman developed significant unilateral anterior cervical and supraclavicular lymphadenopathy 3 days after receiving her first dose (of a total of three doses) of human papilloma virus (HPV) vaccine. She had no history of lymphadenopathy after other previous immunizations, and had received no vaccines other than HPV at that time. The left-sided lymphadenopathy developed after she was vaccinated in the left deltoid muscle. The spatial and temporal relationships between the appearance of the lymphadenopathy and receipt of the vaccine in the absence of other causal agents strongly suggest that the HPV vaccine was the causal agent. Use of the Naranjo adverse drug reaction probability scale indicated that the HPV vaccine was a probable (score of 6) cause of the patient's adverse reaction. The patient received her second dose of the HPV vaccine 2 months later without further lymphadenopathy. To prevent unnecessary lymph node biopsies and patient concern, clinicians should be aware that lymphadenopathy may occur after HPV vaccination.

Late diagnosis of early disseminated lyme disease: perplexing symptoms in a gardener.

The timely diagnosis of early disseminated Lyme disease presenting as multiple secondary erythema migrans lesions is sometimes delayed because this stage is infrequently encountered in a general practice. We report a case of a 60-year-old woman whose initial complaints of an erythematous, "burning" rash and flu-like symptoms led to several laboratory tests with no specific diagnosis. The correct diagnosis was only made after sorting through other possibilities in the differential diagnosis. By reproducing the medical images and reviewing the medical literature, we underscore the importance of including Lyme disease in the list of diagnoses pertaining to diffuse skin rashes in the febrile patient.

The management of keloids: hands-on versus hands-off.

Keloids are benign fibrous growths that appear in scar tissue. The lesions can be severely disfiguring and early recognition of genetic lesions is crucial. This case report outlines and reviews the important management strategies for these lesions and the requirement for extensive counseling for the patient and their family. Many potential medical and surgical interventions exist. Unfortunately, these lesions tend to recur and overall outcomes remain poor. Given patient susceptibility to disfiguring results, surgical intervention should be used with extreme caution.