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Simple cases
Case 15
61-year-old man is referred because of redness and swelling of nose for 2 weeks.
History
How do you feel today?
I feel like I have the flu or something. I don't feel too good.
An acute infection, if severe, may be associated with malaise.
Do you have fever?
I haven't checked.
If a bacterial infection is suspected, measuring the temperature is appropriate. The patient did have a fever38.2°C.
Tell me what has happened in the past two weeks?
My nose is always a bit red and I have a few pustules. But now it is really swollen, throbs, and my cheeks are red.
A sudden change in a chronic condition always requires investigation.
Do you have allergies?
Yes, last year I had some skin allergies.
Question and answer are both too general. A possible severe drug reaction could cause facial swelling but not fever.
Do you drink alcohol?
Hmm, once in a while a beer at night.
Even though a red nose is a caricature for an alcoholic, it is often not true. In addition, the pain and swelling do not fit.
Did you have an injury to your nose, or is the little raw spot on the right side a result of the swelling?
A little blister appear there 2 days ago and then burst.
The time sequence of lesions often helps with the diagnosis.
Is this painful?
Yes, I feel a pressure in my head and my nose throbs.
Pain is one of the classic signs of infection.
Lesion
Choose the right efflorescences:
The skin changes are flat so the general description of macule is correct. Here one would speak of erythema.
Tumor simply means swelling, although edema would be more precise.
There is a yellow crust on the right side of the nose.
Poikiloderma features telangiectases, atrophy, and pigmentary changes. All are missing here.
Although the patient described a small blister, today we only see swelling and glistening from the edema, but no bulla.
Diagnosis
Choose the right diagnosis:
Angioedema does not persist for 2 weeks and is not associated with fever.
The patient does have rosacea but it is not the cause of his acute problem.
Erysipelas is an acute bacterial infection, usually streptococcal, with fever and pain. The sed rate and WBC count are elevated.
Wrong. Sunburn doesn't last two weeks and always peels. Location is also wrong.
Good differential diagnostic consideration. Cutaneous sarcoidosis can selectively involve the nose. This is known as lupus pernio. Usually there are telangiectases and nodules, without acute changes.
Therapy
Choose the right therapy(ies):
Streptococci are still sensitive to Penicillin G. Bed rest is essential to reduce spread of infection.
Mupirocin is used to prevent nasal staphylococcal carriage. It is not suitable for treating this acute infection.
This is the recommended oral approach to erysipelas and the regimen which this patient received.
In the case of penicillin allergy, this is another possibility.
Not suitable treatment for a systemic infection.
