Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 32-year-old man with a rash on his face and midchest

mksap
Conditions
June 4, 2016
6 Shares
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 32-year-old man is evaluated for a 2-week history of a rash on his face and midchest. He describes the rash as consisting of small, reddish “lumps” that are intensely itchy; they develop and begin to resolve with development of new lesions. He otherwise feels well.

Medical history is significant for a recent diagnosis of HIV infection. Medications are tenofovir, emtricitabine, efavirenz, and trimethoprim-sulfamethoxazole. On physical examination, vital signs are normal. The patient has 1- to 3-mm papules and pustules on the face and central chest. There is no crusting or scaling in the web spaces, and no lesions on the umbilicus or penis. There is no lymphadenopathy or facial swelling. The remainder of the physical examination is unremarkable.

Laboratory studies:

Hemoglobin Normal
Leukocyte count 3200/µL (3.2 × 109/L) with 9% eosinophils
Platelet count Normal
CD4 cell count 170/µL
HIV viral load 8000 copies/mL
Creatinine Normal
Liver chemistry tests Normal

Which of the following is the most likely diagnosis?

A: Drug-induced acne
B: Drug reaction with eosinophilia and systemic symptoms (DRESS)
C: Eosinophilic pustular folliculitis
D: Scabies infestation

MKSAP Answer and Critique

The correct answer is C: Eosinophilic pustular folliculitis.

This patient has eosinophilic pustular folliculitis, a rash most commonly seen in patients with HIV infection, and usually in those with a CD4 cell count less than 300/µL. The lesions are typically intensely pruritic papules (and rarely pustules) clustered on the chest and face, generally in areas with a high concentration of sebaceous glands. Biopsy will reveal an eosinophilic infiltrate in the hair follicle, and peripheral eosinophilia may develop in up to 50% of patients. The exact etiology is unknown, but the condition is relatively common. Diagnosis is usually based on the presence of the typical skin rash in an appropriate clinical context. The rash usually responds to antiretroviral therapy, although high-potency glucocorticoids and systemic antihistamines may be used for symptomatic treatment.

Acne is characterized by comedonal lesions (plugged pores, blackheads) and, when drug induced, often involves the shoulders and back; this patient is not taking any drugs typically associated with drug-induced acne (glucocorticoids, bromides, lithium, certain oncologic agents [particularly epidermal growth factor-receptor antagonists], and more).

Drug reaction with eosinophilia and systemic symptoms (DRESS), also referred to as drug-induced hypersensitivity syndrome, would appear within 2 to 8 weeks of starting a new drug and would include fevers, a widespread morbilliform eruption often involving the face accompanied by facial edema, complete blood count abnormalities (eosinophilia or atypical lymphocytosis), and systemic inflammation (generally lymphadenopathy and hepatitis, although nephritis, pneumonitis, and myocarditis can occur). This patient lacks the fever and systemic symptoms of DRESS, and the rash would be atypical for this diagnosis.

Scabies can also cause intense pruritus and eosinophilia. However, patients rarely have lesions above the neck and generally have involvement of the finger web spaces, umbilicus, and, in men, the genitals.

Key Point

  • Eosinophilic pustular folliculitis causes intensely pruritic papules on the face and chest and is most commonly seen in patients with HIV infection, generally with a CD4 cell count less than 300/µL.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

An open letter to Macklemore about the opioid epidemic

June 3, 2016 Kevin 2
…
Next

Compassionate care is at it's best when selflessly focused on helping others

June 4, 2016 Kevin 3
…

Tagged as: Dermatology

Post navigation

< Previous Post
An open letter to Macklemore about the opioid epidemic
Next Post >
Compassionate care is at it's best when selflessly focused on helping others

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • The breakthroughs and failures of medicine

    Shannon Casey, PA-C
  • A call for cost transparency

    Mukul Mehra, MD
  • It’s always easier to judge someone’s failures from higher ground

    Michael Kirsch, MD

More in Conditions

  • Breaking down barriers: How technology is improving diabetes management in underserved communities

    Anonymous
  • Yoga and self-care won’t cure my Crohn’s disease

    Kristen L. Cole
  • What causes fainting and how to prevent it during needle procedures

    Jean Paul Brutus, MD
  • Healing through love and spirituality

    John T. James, PhD
  • Lifestyle change: the forgotten solution in health care

    Tyler Petersen
  • Breaking the cycle of childhood obesity

    Martin C. Young, MD
  • Most Popular

  • Past Week

    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • From physician to patient: one doctor’s journey to finding purpose after a devastating injury

      Stephanie Pearson, MD | Physician
    • An unspoken truth about non-compete clauses in medicine

      Harry Severance, MD | Policy
    • Fostering the next (diverse) generation of clinicians

      Imamu Tomlinson, MD, MBA | Physician
    • Healing through love and spirituality

      John T. James, PhD | Conditions
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Why are doctors sued and politicians aren’t?

      Kellie Lease Stecher, MD | Physician
  • Recent Posts

    • Rescuing primary care: the role of health administrators [PODCAST]

      The Podcast by KevinMD | Podcast
    • Breaking down barriers: How technology is improving diabetes management in underserved communities

      Anonymous | Conditions
    • From penicillin to digital health: the impact of social media on medicine

      Homer Moutran, MD, MBA, Caline El-Khoury, PhD, and Danielle Wilson | Social media
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • How to overcome telemedicine’s biggest obstacles

      Harvey Castro, MD, MBA | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Investigational ALS Drug May Have Clinical Benefit, FDA Staff Says
  • Cases of Deadly Fungus Tripled in Past Few Years, CDC Says
  • Small Gains in Cardiorespiratory Fitness Track With Improved Longevity
  • Improved OS With Hyperfractionated RT in Recurrent Nasopharyngeal Carcinoma
  • GPT-4 Is Here. How Can Doctors Use Generative AI Now?

Meeting Coverage

  • Rapid Improvement in Atopic Dermatitis With Topical PDE4 Inhibitor
  • New Approaches in the Bladder-Sparing Paradigm
  • Response Rates in Hidradenitis Suppurativa Continue to Climb With New Therapies
  • Another Win for a JAK Inhibitor in Alopecia Areata
  • Biologic Switch Revs Up Response in Plaque Psoriasis
  • Most Popular

  • Past Week

    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • From physician to patient: one doctor’s journey to finding purpose after a devastating injury

      Stephanie Pearson, MD | Physician
    • An unspoken truth about non-compete clauses in medicine

      Harry Severance, MD | Policy
    • Fostering the next (diverse) generation of clinicians

      Imamu Tomlinson, MD, MBA | Physician
    • Healing through love and spirituality

      John T. James, PhD | Conditions
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Why are doctors sued and politicians aren’t?

      Kellie Lease Stecher, MD | Physician
  • Recent Posts

    • Rescuing primary care: the role of health administrators [PODCAST]

      The Podcast by KevinMD | Podcast
    • Breaking down barriers: How technology is improving diabetes management in underserved communities

      Anonymous | Conditions
    • From penicillin to digital health: the impact of social media on medicine

      Homer Moutran, MD, MBA, Caline El-Khoury, PhD, and Danielle Wilson | Social media
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • How to overcome telemedicine’s biggest obstacles

      Harvey Castro, MD, MBA | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

MKSAP: 32-year-old man with a rash on his face and midchest
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...