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Simple cases
Case 20
35-year-old man presented with sudden intensely pruritic red lesions on neck, chin, back and arms
History
Why brings you here today?
I have had these red spots all over for a few days.
A totally neutral question is sometimes a good way to start the history. It usually brings the most information. Now we need to explore a bit more.
Do these red spots bother you?
Yes, they itch like the devil. I am really nervous and I can't sleep at night.
Severe pruritus is typical for this disorder.
You said the spots are everywhere. Where are they exactly?
On my back, upper arms, and neck.
Typically these lesions are distributed in an asymmetric fashion on covered body areas.
Have you taken any medications?
Yes, I take an aspirin once in a while for headache. The last one was 2 weeks ago.
A medication history is always important to explore the possibility of a drug reaction and to help in planning therapy.
Have you been out of the country recently?
Yes, I was in Budapest last week. I lived in a real dump there, but it was cheap. Before that, I was in Tunisia last year.
The history of a cheap hotel, presumably less than perfectly clean, helps with the diagnosis.
Did you have sexual contacts there?
No.
This question is unnecessary here. This disease is not transmitted sexually.
Lesion
Choose the right efflorescences:
False. There is no fluid-filled space. Try again.
Correct, multiple erythematous urticarial papules are present. Many have a central hemorrhagic punctum, typical for a bite, and some are arranged in small groups, suggesting an insect <<stopped and fed>>.
False. The lesions are raisedthus not macules.
Diagnosis
Choose the right diagnosis:
The pruritic papules in urticaria are transient, coming and going. While our patient's lesions resembling urticaria, they are persistent.
False. There is no history of ingestion and the lesions do not fit with drug reaction.
Flea bites or pulicosis is caused by fleas from animals or from the immediate environment (clothes, furniture, cracks in wall). The bites typically have a central hemorrhagic punctum and are highly pruritic.
In folliculitis, the lesions are centered around hair follicles and usually not intensely pruritic.
False. Here the assassin is larva of garden mites, so the history is of outdoor exposure and the lesions are on exposed skin.
Therapy
Choose the right therapy(ies):
Fleas are only temporarily on the body. No antiparasitic medication is needed.
Correct. Good way to control itch.
Another possible way to help with the itch.
In general, advisable, but not helpful here since the bites most likely occurred in Hungary.
If re-exposure is expected, then a wise choice.
Test
The following questions are related to the current case. Try to solve them.
