Global Dermatology Grand Rounds:
Case of the Month: April 1996
submitted by Dr. Rhett Drugge

September 1996



August 1996

June 1996

May 1996

April 1996

July 1995

June 1995

May 1995

February 1995

 January 1995

Click on the thumbnail sketches to view the clinical and histologic images.

Chief Complaint: Severe Recurrent Blisters

History of Present Illness: This 9 month old black male presents with a 6.5 month history of a blistering disorder. The initial onset of the lesions was on the chest where the patient had developed an region of depigmentation on the central chest which the parents complained were the result of "bubbling up" of the skin. This occurred one and a half weeks after the patient had received his 2 month immunization (DPT, Polio oral, HID). The patient used a mid-potency cortisone cream at this time which resolved the generalized pruritis. 8 weeks later, January of 1996, a second episode culminated in hospitalization for a severe blistering eruption associated with severe pruritis which responded rapidly to solumedrol I.V., 2mg/kg/day. After the hospitalization, the patient was tapered off of cortisone with oral prednisone over a month's time. This second eruption followed the second immunization which the patient had recieved by one week. In the weeks after withdrawal from the medication, the patient was noted to have welts on the skin after eating wheat based cereal. The patient was then placed on a gluten-free diet. One week prior to hospitalization, the patient was noted to have several vesicles on the right shoulder. This was biopsied (see slides above). In April of 1996, the patient was admitted to the hospital with what clinically resembles the same condition. The parents noted that the attack was associated with diarrhea which "burned the patient's skin. One of the items of suspicion was a red juice given to the infant in the evening, and the patient did not sleep that night from itching and blisters formed the following day. An allergy testing with a blood sample was suggested. The patient was put on prednisone up to 2mg/kg/6 hours until no new blisters were forming, and then tapered off the medication over a three week period..

Immunizations: 2, 4 and 6 months Medications: Prednisone 1 mg/kg/day (tapering)

Physical examination on hospitalization: Lethargic appearing BM infant with generalized vesicles and blisters on the trunk and upper extremeties, with lower extremity. The scalp is involved as is the groin.

Laboratory Examinations:

November, 1995 Direct Immunofluorescence: January, 1996, Results: Negative
Biopsy of the right shoulder: February, 1996. (see slides above) H&E stain of a right shoulder blister show a heavy mononuclear dermal infiltrate with numerous eosinophils. Intraepidermal paucicellular vesicobullae are present with occ. eosinophils.

Clinical Impression:

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Global Dermatology Grand Rounds
Rhett J. Drugge, M.D., Founding Editor
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Stamford, CT 06902 USA
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