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
November 11, 2017
1 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

We all treat the whole patient. We must avoid tunnel vision at all costs.

November 10, 2017 Kevin 1
…
Next

Veterans deserve our full attention

November 11, 2017 Kevin 0
…

Tagged as: Dermatology, Infectious Disease

Post navigation

< Previous Post
We all treat the whole patient. We must avoid tunnel vision at all costs.
Next Post >
Veterans deserve our full attention

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

  • Physician autonomy and patient interactions in corporate health care

    Michele Luckenbaugh
  • Vague criteria can lead to misdiagnosis and prison

    L. Joseph Parker, MD
  • U.S. maternal mortality crisis: a deep dive

    Alan Lindemann, MD
  • Contemporary weight loss: Unveiling the quest for elusive elixir

    Osmund Agbo, MD
  • Why patients write: stress relief, self-care, and sharing experiences

    R. Lynn Barnett
  • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

    Angel Garcia Otano, MD
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Ketamine for mental health conditions: What every primary care physician needs to know

      Carlene MacMillan, MD & L. Alison McInnes, MD | Meds
    • Physician autonomy and patient interactions in corporate health care

      Michele Luckenbaugh | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • 1 in 4 attempt suicide: the persecution of autistic physicians

      Patricia Celan, MD | Physician
  • Recent Posts

    • Physician autonomy and patient interactions in corporate health care

      Michele Luckenbaugh | Conditions
    • PSA screening: What you need to know [PODCAST]

      The Podcast by KevinMD | Podcast
    • Vague criteria can lead to misdiagnosis and prison

      L. Joseph Parker, MD | Conditions
    • U.S. maternal mortality crisis: a deep dive

      Alan Lindemann, MD | Conditions
    • Lively communication in the service industry

      Deepak Gupta, MD | Physician
    • Contemporary weight loss: Unveiling the quest for elusive elixir

      Osmund Agbo, MD | Conditions

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

Leave a Comment

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

  • 'Not Clear If the Juice Is Worth the Squeeze': What We Heard This Week
  • Avoiding Male Doctors Is Not Discrimination. It May Be Risk Aversion.
  • What Is the 'Carrot Tan' Trending on Social Media? A Dermatologist Weighs In
  • Did Gabapentin Improve Post-COVID Olfaction?
  • Fentanyl Death Trends; Food Additives and Heart Disease

Meeting Coverage

  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • ERS Roundup: Cell Transplant Boosts Lung Function in COPD Patients
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Ketamine for mental health conditions: What every primary care physician needs to know

      Carlene MacMillan, MD & L. Alison McInnes, MD | Meds
    • Physician autonomy and patient interactions in corporate health care

      Michele Luckenbaugh | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • 1 in 4 attempt suicide: the persecution of autistic physicians

      Patricia Celan, MD | Physician
  • Recent Posts

    • Physician autonomy and patient interactions in corporate health care

      Michele Luckenbaugh | Conditions
    • PSA screening: What you need to know [PODCAST]

      The Podcast by KevinMD | Podcast
    • Vague criteria can lead to misdiagnosis and prison

      L. Joseph Parker, MD | Conditions
    • U.S. maternal mortality crisis: a deep dive

      Alan Lindemann, MD | Conditions
    • Lively communication in the service industry

      Deepak Gupta, MD | Physician
    • Contemporary weight loss: Unveiling the quest for elusive elixir

      Osmund Agbo, MD | Conditions

MedPage Today Professional

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

Leave a Comment

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

Loading Comments...