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Postpartum Psychosis in a Young VA Patient (Quiz)
Postpartum psychosis is identified in 1 to 2 per 1,000 childbirths. In women who have had an earlier episode of postpartum psychosis or have a diagnosis of bipolar disorder, the rate is up to 100 times higher.1 Kendell and colleagues found that psychiatric admissions occurred at a rate 7 times higher in the 30 days after birth than in the prepregnancy period, suggesting that metabolic factors might be involved in triggering postpartum psychotic symptoms.12 An abrupt hormonal loss occurs at childbirth; hormones peak 200-fold during gestation and decline rapidly within a day after birth.9 Despite the severity of symptoms in postpartum psychosis, these patients tend to have a better prognosis than that of women with psychotic episodes not related to pregnancy.4
Click here to read the full article
Postpartum psychosis is identified in 1 to 2 per 1,000 childbirths. In women who have had an earlier episode of postpartum psychosis or have a diagnosis of bipolar disorder, the rate is up to 100 times higher.1 Kendell and colleagues found that psychiatric admissions occurred at a rate 7 times higher in the 30 days after birth than in the prepregnancy period, suggesting that metabolic factors might be involved in triggering postpartum psychotic symptoms.12 An abrupt hormonal loss occurs at childbirth; hormones peak 200-fold during gestation and decline rapidly within a day after birth.9 Despite the severity of symptoms in postpartum psychosis, these patients tend to have a better prognosis than that of women with psychotic episodes not related to pregnancy.4
Click here to read the full article
Postpartum psychosis is identified in 1 to 2 per 1,000 childbirths. In women who have had an earlier episode of postpartum psychosis or have a diagnosis of bipolar disorder, the rate is up to 100 times higher.1 Kendell and colleagues found that psychiatric admissions occurred at a rate 7 times higher in the 30 days after birth than in the prepregnancy period, suggesting that metabolic factors might be involved in triggering postpartum psychotic symptoms.12 An abrupt hormonal loss occurs at childbirth; hormones peak 200-fold during gestation and decline rapidly within a day after birth.9 Despite the severity of symptoms in postpartum psychosis, these patients tend to have a better prognosis than that of women with psychotic episodes not related to pregnancy.4
Click here to read the full article
Postpartum psychosis can present with a prodromal phase consisting of fatigue, insomnia, restlessness, tearfulness, and emotional lability, making early identification difficult. Later, florid psychotic symptoms can include suspiciousness, confusion, incoherence, irrational statements, obsessive concern about the infant’s health, and delusions, including a belief that the baby is dead or defective. Some women might deny that the birth occurred or feel that they are unmarried, virginal, or persecuted.1 More concerning symptoms include auditory hallucinations commanding the mother to harm or kill the infant and/or herself. Symptoms often begin within days to weeks of birth, usually 2 to 3 weeks after delivery but can occur as long as 8 weeks postpartum.1 Several cases of infanticide and suicide have been documented.1 The risk of experiencing another psychotic episode in subsequent pregnancies can be as high as 50%.4-6 Regardless of symptom severity at onset, postpartum psychosis is a psychiatric emergency and must be treated as such.
As Girl Grows, Lesions Follow Suit
ANSWER
The correct diagnosis in this case is juvenile xanthogranuloma (JXG; choice “d”).
Anderson-Fabry disease (choice “a”) is a rare inherited disorder characterized by widespread red papules; these lesions, however, are much smaller and far more widespread than those of JXG.
Considered a possibility at initial presentation, molluscum contagiosum (choice “b”) was quickly ruled out upon further inspection. This patient’s condition lacked the typical features of molluscum: umbilicated, white, firm papules caused by a pox virus.
Eruptive xanthomata (choice “c”) is a collection of lipid-laden macrophages caused by hypertriglyceridemia. They present as papules and nodules under, rather than on, the skin.
DISCUSSION
Solitary JXG lesions are fairly common, developing on the trunk, face, or extremities as smooth, reddish brown to cream papules. Typically, they cause no problems—but when multiple lesions manifest at birth, the condition can affect the eye (especially the iris, as in this case).
JXG is considered a form of histiocytosis, specifically classified as a type II non-Langerhans cell-mediated lesion. It is believed to result from a disordered macrophage response to a nonspecific tissue injury, which leads to a distinct variety of granulomatous change. These lesions are part of a spectrum of related conditions that also includes Langerhans cell histiocytosis.
No perfect treatment exists for this patient’s multitudinous skin lesions, because her darker skin could easily be permanently changed by burning, freezing, laser, or other destructive modality. Fair or not, in many cases, insurance coverage (or lack thereof) ultimately dictates what treatment is used.
Once the biopsy confirmed the diagnosis and effectively ruled out the other items in the differential, she was referred to ophthalmology for ongoing care of her eyes. Beyond that, she’ll need an annual physical with labs, because JXG is known to affect internal organs as well.
ANSWER
The correct diagnosis in this case is juvenile xanthogranuloma (JXG; choice “d”).
Anderson-Fabry disease (choice “a”) is a rare inherited disorder characterized by widespread red papules; these lesions, however, are much smaller and far more widespread than those of JXG.
Considered a possibility at initial presentation, molluscum contagiosum (choice “b”) was quickly ruled out upon further inspection. This patient’s condition lacked the typical features of molluscum: umbilicated, white, firm papules caused by a pox virus.
Eruptive xanthomata (choice “c”) is a collection of lipid-laden macrophages caused by hypertriglyceridemia. They present as papules and nodules under, rather than on, the skin.
DISCUSSION
Solitary JXG lesions are fairly common, developing on the trunk, face, or extremities as smooth, reddish brown to cream papules. Typically, they cause no problems—but when multiple lesions manifest at birth, the condition can affect the eye (especially the iris, as in this case).
JXG is considered a form of histiocytosis, specifically classified as a type II non-Langerhans cell-mediated lesion. It is believed to result from a disordered macrophage response to a nonspecific tissue injury, which leads to a distinct variety of granulomatous change. These lesions are part of a spectrum of related conditions that also includes Langerhans cell histiocytosis.
No perfect treatment exists for this patient’s multitudinous skin lesions, because her darker skin could easily be permanently changed by burning, freezing, laser, or other destructive modality. Fair or not, in many cases, insurance coverage (or lack thereof) ultimately dictates what treatment is used.
Once the biopsy confirmed the diagnosis and effectively ruled out the other items in the differential, she was referred to ophthalmology for ongoing care of her eyes. Beyond that, she’ll need an annual physical with labs, because JXG is known to affect internal organs as well.
ANSWER
The correct diagnosis in this case is juvenile xanthogranuloma (JXG; choice “d”).
Anderson-Fabry disease (choice “a”) is a rare inherited disorder characterized by widespread red papules; these lesions, however, are much smaller and far more widespread than those of JXG.
Considered a possibility at initial presentation, molluscum contagiosum (choice “b”) was quickly ruled out upon further inspection. This patient’s condition lacked the typical features of molluscum: umbilicated, white, firm papules caused by a pox virus.
Eruptive xanthomata (choice “c”) is a collection of lipid-laden macrophages caused by hypertriglyceridemia. They present as papules and nodules under, rather than on, the skin.
DISCUSSION
Solitary JXG lesions are fairly common, developing on the trunk, face, or extremities as smooth, reddish brown to cream papules. Typically, they cause no problems—but when multiple lesions manifest at birth, the condition can affect the eye (especially the iris, as in this case).
JXG is considered a form of histiocytosis, specifically classified as a type II non-Langerhans cell-mediated lesion. It is believed to result from a disordered macrophage response to a nonspecific tissue injury, which leads to a distinct variety of granulomatous change. These lesions are part of a spectrum of related conditions that also includes Langerhans cell histiocytosis.
No perfect treatment exists for this patient’s multitudinous skin lesions, because her darker skin could easily be permanently changed by burning, freezing, laser, or other destructive modality. Fair or not, in many cases, insurance coverage (or lack thereof) ultimately dictates what treatment is used.
Once the biopsy confirmed the diagnosis and effectively ruled out the other items in the differential, she was referred to ophthalmology for ongoing care of her eyes. Beyond that, she’ll need an annual physical with labs, because JXG is known to affect internal organs as well.
Since shortly after birth, a now 12-year-old African-American girl has had lesions on her trunk. She has never been given a diagnosis and has always been told she would “outgrow the problem.” Instead, the number and distribution of lesions continues to increase, and her pediatrician finally refers her to dermatology for evaluation.
About 150 to 200 nearly identical lesions scatter around the patient’s body, clustered mostly on the left upper back but also on the abdomen and bilateral upper thighs. The fleshy, reddish brown, mushroom-like papules range in size from 2 to 4 mm and exhibit no central umbilication. Two brown spots (each measuring 2 mm) are seen in the iris of the patient’s left eye.
There are no other apparent medical problems to report and no visual deficits. Aside from being unsightly, the lesions are asymptomatic. A shave biopsy of one of them is performed.
Man Thrown From Balky Bike
ANSWER
The radiograph does not demonstrate any evidence of acute chest or intrathoracic injury. Of note, it appears that the left humerus is dislocated anteriorly and inferiorly.
Dedicated shoulder radiographs were obtained, which confirmed the dislocation with no evidence of fracture. Orthopedics was consulted for evaluation and subsequent reduction.
ANSWER
The radiograph does not demonstrate any evidence of acute chest or intrathoracic injury. Of note, it appears that the left humerus is dislocated anteriorly and inferiorly.
Dedicated shoulder radiographs were obtained, which confirmed the dislocation with no evidence of fracture. Orthopedics was consulted for evaluation and subsequent reduction.
ANSWER
The radiograph does not demonstrate any evidence of acute chest or intrathoracic injury. Of note, it appears that the left humerus is dislocated anteriorly and inferiorly.
Dedicated shoulder radiographs were obtained, which confirmed the dislocation with no evidence of fracture. Orthopedics was consulted for evaluation and subsequent reduction.
A 55-year-old man is brought to your facility following a motorcycle accident. He was a helmeted rider who was inadvertently thrown from the motorcycle when the accelerator got stuck. Bystanders reported he had brief loss of consciousness, but upon arrival to your facility, he is awake.
History is limited as the patient is confused and repetitive in his speech, indicating he is post concussive. He is complaining of head, face, and chest wall pain. His vital signs are all within normal limits; he is hemodynamically stable. His O2 saturation is 98% on room air. Breath sounds are clear.
As you are completing your primary survey, portable chest and pelvic radiographs are obtained. The chest radiograph is shown. What is your impression?
A Creepy Crawly Anomaly
ANSWER
The correct answer is dermatofibroma (choice “c”), based on the classic histologic picture and the lack of supportive findings for other items in the differential. These include seborrheic keratosis, granular cell tumor, basal cell carcinoma, and sweat duct cancer.
DISCUSSION
This is a perfect example of one of the most common benign tumors, seen daily in dermatology offices worldwide. Alternately referred to as superficial benign fibrous histiocytomas, dermatofibromas (DFs) typically manifest on lower extremities, are about twice as common in women as in men, and usually affect patients in their early 40s.
DFs appear most commonly as low, firm, round to ovoid, pinkish brown papules that dimple with lateral digital pressure. Though not pathognomic, the “dimple sign” is highly suggestive of this diagnosis. DF lesions can also manifest as firm, convex papules or nodules (as in this case) with the same coloring but without the dimple sign.
For years, DFs were believed to be a reaction to trauma (eg, bug bite). While this theory still has its adherents, more recent studies suggest these are true tumors composed of skin fibroblasts. Their ability to occur internally, even in bone, provides further evidence against their putatively reactive nature.
Histologically, the typical DF shows whorling fascicles of a fibroblastic spindle cell proliferation in the dermis. By contrast, the most dangerous item in the differential, the rare but greatly feared malignant dermatofibrosarcoma protuberans, is characterized by a storiform (cartwheel-shaped) pattern of spindle cells.
DFs are often subject to trauma from shaving and therefore surgically removed. However, since this was not the case for this patient, she chose to leave her lesion in place.
ANSWER
The correct answer is dermatofibroma (choice “c”), based on the classic histologic picture and the lack of supportive findings for other items in the differential. These include seborrheic keratosis, granular cell tumor, basal cell carcinoma, and sweat duct cancer.
DISCUSSION
This is a perfect example of one of the most common benign tumors, seen daily in dermatology offices worldwide. Alternately referred to as superficial benign fibrous histiocytomas, dermatofibromas (DFs) typically manifest on lower extremities, are about twice as common in women as in men, and usually affect patients in their early 40s.
DFs appear most commonly as low, firm, round to ovoid, pinkish brown papules that dimple with lateral digital pressure. Though not pathognomic, the “dimple sign” is highly suggestive of this diagnosis. DF lesions can also manifest as firm, convex papules or nodules (as in this case) with the same coloring but without the dimple sign.
For years, DFs were believed to be a reaction to trauma (eg, bug bite). While this theory still has its adherents, more recent studies suggest these are true tumors composed of skin fibroblasts. Their ability to occur internally, even in bone, provides further evidence against their putatively reactive nature.
Histologically, the typical DF shows whorling fascicles of a fibroblastic spindle cell proliferation in the dermis. By contrast, the most dangerous item in the differential, the rare but greatly feared malignant dermatofibrosarcoma protuberans, is characterized by a storiform (cartwheel-shaped) pattern of spindle cells.
DFs are often subject to trauma from shaving and therefore surgically removed. However, since this was not the case for this patient, she chose to leave her lesion in place.
ANSWER
The correct answer is dermatofibroma (choice “c”), based on the classic histologic picture and the lack of supportive findings for other items in the differential. These include seborrheic keratosis, granular cell tumor, basal cell carcinoma, and sweat duct cancer.
DISCUSSION
This is a perfect example of one of the most common benign tumors, seen daily in dermatology offices worldwide. Alternately referred to as superficial benign fibrous histiocytomas, dermatofibromas (DFs) typically manifest on lower extremities, are about twice as common in women as in men, and usually affect patients in their early 40s.
DFs appear most commonly as low, firm, round to ovoid, pinkish brown papules that dimple with lateral digital pressure. Though not pathognomic, the “dimple sign” is highly suggestive of this diagnosis. DF lesions can also manifest as firm, convex papules or nodules (as in this case) with the same coloring but without the dimple sign.
For years, DFs were believed to be a reaction to trauma (eg, bug bite). While this theory still has its adherents, more recent studies suggest these are true tumors composed of skin fibroblasts. Their ability to occur internally, even in bone, provides further evidence against their putatively reactive nature.
Histologically, the typical DF shows whorling fascicles of a fibroblastic spindle cell proliferation in the dermis. By contrast, the most dangerous item in the differential, the rare but greatly feared malignant dermatofibrosarcoma protuberans, is characterized by a storiform (cartwheel-shaped) pattern of spindle cells.
DFs are often subject to trauma from shaving and therefore surgically removed. However, since this was not the case for this patient, she chose to leave her lesion in place.
A 48-year-old woman is referred to dermatology for examination of a lesion on her ankle. Although the patient is certain that it has remained unchanged for years, she takes her primary care provider’s recommendation and agrees to be seen. She says the lesion occasionally itches and has a “crawly” feeling to it, but its size remains consistent.
Located on the lateral aspect of her left ankle is a brownish red, firm, round, intradermal nodule. It measures 8.5 mm and has a faint brown macular halo around it. Biopsy shows multiple round fascicles of spindle cells proliferating in the dermis. Special stains rule out the possibility of dermatofibrosarcoma protuberans, the most serious item in the differential.
The patient’s medical history includes breast cancer and a significant family history of skin cancer.
Fast Track to Abdominal Pain
ANSWER
The radiograph illustrates a large calcification within the right upper quadrant—most likely a gallstone. Several smaller calcifications are clustered together in the same area, making the diagnosis cholelithiasis. The patient was referred to the general surgery clinic for further
evaluation.
For recent findings on gallstone disease and heart risk, see here.
ANSWER
The radiograph illustrates a large calcification within the right upper quadrant—most likely a gallstone. Several smaller calcifications are clustered together in the same area, making the diagnosis cholelithiasis. The patient was referred to the general surgery clinic for further
evaluation.
For recent findings on gallstone disease and heart risk, see here.
ANSWER
The radiograph illustrates a large calcification within the right upper quadrant—most likely a gallstone. Several smaller calcifications are clustered together in the same area, making the diagnosis cholelithiasis. The patient was referred to the general surgery clinic for further
evaluation.
For recent findings on gallstone disease and heart risk, see here.
An NP student you are precepting in the emergency department fast track area presents her patient to you: a 60-year-old woman with abdominal pain. The pain is chronic but has worsened slightly, prompting the patient, who does not have a primary care provider, to present today. She experiences occasional nausea but no fever, and she denies any bowel or bladder complaints other than constipation. Her medical history is significant for mild hypertension.
On exam, your student notes an obese female who is in no obvious distress. The patient’s vital signs are all within normal limits. The abdominal exam is unimpressive, revealing a soft abdomen with good bowel sounds. Although she does have mild diffuse tenderness, she has no rebound or guarding.
Although your student suspects the patient is just constipated, she orders blood work and urinalysis. An abdominal survey is obtained as well. What is your impression?
His Head Is In the Game–His Heart, Not So Much
ANSWER
The correct interpretation includes normal sinus rhythm with a new anterior myocardial infarction (MI) and inferolateral injury.
Criteria for an anterior MI include Q waves in leads V2 to V6 and hyperacute ST-T wave changes. V1 is usually spared.
Inferolateral injury is evidenced by the presence of Q waves and absence of R waves in leads III and aVF.
The patient’s cardiac catheterization revealed left anterior descending and circumflex artery disease.
ANSWER
The correct interpretation includes normal sinus rhythm with a new anterior myocardial infarction (MI) and inferolateral injury.
Criteria for an anterior MI include Q waves in leads V2 to V6 and hyperacute ST-T wave changes. V1 is usually spared.
Inferolateral injury is evidenced by the presence of Q waves and absence of R waves in leads III and aVF.
The patient’s cardiac catheterization revealed left anterior descending and circumflex artery disease.
ANSWER
The correct interpretation includes normal sinus rhythm with a new anterior myocardial infarction (MI) and inferolateral injury.
Criteria for an anterior MI include Q waves in leads V2 to V6 and hyperacute ST-T wave changes. V1 is usually spared.
Inferolateral injury is evidenced by the presence of Q waves and absence of R waves in leads III and aVF.
The patient’s cardiac catheterization revealed left anterior descending and circumflex artery disease.
While playing in a company racquetball tournament, a 47-year-old man suddenly collapses. He is unresponsive, without a pulse, and his coworkers immediately initiate CPR. A single shock from an on-site AED successfully resuscitates him from ventricular fibrillation. Paramedics arrive within 12 minutes, by which time the patient is conscious and responsive to commands.
During transportation to the emergency department, however, he develops ventricular tachycardia and loses consciousness; a single shock cardioverts him to normal sinus rhythm. An ECG is ordered and the cardiac catheterization team mobilized.
While waiting, you contact the patient’s wife by telephone. She tells you that her husband has been complaining of chest discomfort for the past week and woke up two nights ago with what he described as “indigestion.” She says she suggested he see a clinician, and he agreed to do so—but not until after the tournament.
His medical history is remarkable only for chronic gastroesophageal reflux disease (GERD), for which he takes chewable antacids on a daily basis. He has no prior cardiac or pulmonary history. There is no surgical history apart from a tonsillectomy in childhood.
The patient is the Chief Operating Officer at a local manufacturing facility. He is married and has three children. His parents and grandparents are alive and in good health, aside from some arthritis in the older generation.
The review of systems, obtained from his wife, is noncontributory. She says he is in excellent health—he jogs, rides mountain bikes, and enjoys racquetball. Her husband attributed his recent chest discomfort to GERD; when she asked if it could be cardiac related, he adamantly denied the possibility, as he was in “excellent health” with “good genes.”
Vital signs include a blood pressure of 118/56 mm Hg; pulse, 80 beats/min; respiratory rate, 18 breaths/min-1; and O2 saturation, 100% on 2 L oxygen. He is afebrile.
Physical exam reveals a thin, otherwise healthy male who appears anxious and apprehensive. He denies ongoing chest pain but states that his chest wall is sore beneath the defibrillator pads. A focal exam reveals normal lung sounds and a regular rate and rhythm with no murmurs, gallops, or rubs. The abdomen is soft and nontender. All peripheral pulses are strong and equal bilaterally, and there are no focal neurologic signs.
The ECG taken at admission shows a ventricular rate of 80 beats/min; PR interval, 162 ms; QRS duration, 106 ms; QT/QTc interval, 370/426 ms; P axis, 51°; R axis, –20°; and T axis, 70°. What is your interpretation of the ECG?
Reticular Hyperpigmentation on the Lower Legs
The Diagnosis: Erythema Ab Igne
Given the patient's reticulated hyperpigmented lesions in the setting of recent space heater use with heater closer to the more affected leg, erythema ab igne was diagnosed. Patient education was provided and moving the heater away from the lower extremities was advised.
Erythema ab igne first was described by German dermatologist Abraham Buschke as hitze melanose, meaning melanosis induced by heat. The classic skin findings were first observed on the lower legs of patients who worked in front of open fires or coal stoves.1 Over the years, new causes of erythema ab igne secondary to prolonged thermal radiation exposure have been reported.1 In the elderly, hospitalized, and chronic pain patients, erythema ab igne has been observed in areas treated with heating pads and blankets.2 Other triggers such as frequent hot bathing, furniture, steam radiators, space heaters, and laptops also have been reported.3-6 Laptop-induced erythema ab igne is a diagnosis that has been reported in the last decade and its incidence likely will increase in the future.6
The clinical manifestations of erythema ab igne correlate with the frequency and duration of heat exposure. Acutely, a mild and transient erythema develops in the affected area. With chronic heat exposure, these areas subsequently develop a permanent reticulated hyperpigmented pattern and may eventually become atrophic.2,6 All body surfaces are at risk, but erythema ab igne classically involves the legs, lower back, and/or abdomen. Lesions typically are asymptomatic; however, burning and pruritus can be present.2,6 Bullous erythema ab igne, though rare, has been reported,7 suggesting a potential transition from erythema ab igne to burns.6
Biopsy is not recommended for diagnosis; however, the histopathologic changes of erythema ab igne include hyperkeratosis, interface dermatitis, epidermal atrophy with apoptotic keratinocytes, and melanin incontinence. Although this condition typically is benign, histologic findings could resemble actinic keratosis, suggesting that chronic changes induced by infrared thermal radiation may lead to squamous cell carcinoma or rarely Merkel cell carcinoma. The latency for developing carcinoma appears to extend 30 years, with a 30% tendency for recurrence or metastasis. Given the possibility of an increase in erythema ab igne in the pediatric population in the upcoming years, as displayed by our patient, and increasing laptop and electronic use in children and adolescents, it is important to be aware of this skin condition and the potential complications of it going undiagnosed.2,6
No specific therapy for erythema ab igne exists. Treatment is centered on eliminating exposure to the heat source. With appropriate removal, the reticulated hyperpigmented lesions will resolve, sometimes taking several months.
Differential diagnosis includes livedo reticularis, livedoid vasculopathy, and cutis marmorata. The reticulated purpuric lesions of livedo reticularis involving the extremities often mimic erythema ab igne's cutaneous morphology; however, livedo reticularis frequently is associated with conditions such as drug reactions, infections, thrombosis, and vasculitides,2 as opposed to erythema ab igne, which frequently is associated with conditions causing pain or decreased body temperature, thus necessitating use of heating devices, as seen in our patient. Livedoid vasculopathy is characterized by purpuric macules involving the lower legs and feet that progress to recurrent leg ulcers. Our patient's asymptomatic lesions and absence of ulcers excluded this diagnosis.8 Lastly, cutis marmorata, a congenital condition, is characterized by blue-violet vascular networks that often display ulceration and atrophy of the involved skin as well as hypertrophy or atrophy of the involved limb9; these clinical findings were not present in our patient and this diagnosis would not explain the relationship between the cutaneous lesions and heat exposure.
- Nilic M, Adams BB. Erythema ab igne induced by a laptop computer. J Am Acad Dermatol. 2004;50:973-974.
- Riahi RR, Cohen PR, Robinson FW, et al. Erythema ab igne mimicking livedo reticularis. Int J Dermatol. 2010;49:1314-1317.
- Lin SJ, Hsu CJ, Chiu HC. Erythema ab igne caused by frequent hot bathing. Acta Derm Venereol. 2002;82:478-479.
- Meffert JJ, Davis BM. Furniture-induced erythema ab igne. J Am Acad Dermatol. 1996;34:516-517.
- Kligman LH, Kligman AM. Reflections on heat. Br J Dermatol. 1984;110:369-375.
- Arnold AW, Itin PH. Laptop computer−induced erythema ab igne in a child and review of the literature [published online October 4, 2010]. Pediatrics. 2010;126:e1227-e1230.
- Kokturk A, Kaya TI, Baz K, et al. Bullous erythema ab igne. Dermatol Online J. 2003;9:18.
- Khenifer S, Thomas L, Balme B, et al. Livedoid vasculopathy: thrombotic or inflammatory disease? Clin Exp Dermatol. 2009;35:693-698.
- Pernet C, Guillot B, Bigorre M, et al. Focal and atrophic cutis marmorata telangiectatica congenital. J Am Acad Dermatol. 2013;69:e268-e269.
The Diagnosis: Erythema Ab Igne
Given the patient's reticulated hyperpigmented lesions in the setting of recent space heater use with heater closer to the more affected leg, erythema ab igne was diagnosed. Patient education was provided and moving the heater away from the lower extremities was advised.
Erythema ab igne first was described by German dermatologist Abraham Buschke as hitze melanose, meaning melanosis induced by heat. The classic skin findings were first observed on the lower legs of patients who worked in front of open fires or coal stoves.1 Over the years, new causes of erythema ab igne secondary to prolonged thermal radiation exposure have been reported.1 In the elderly, hospitalized, and chronic pain patients, erythema ab igne has been observed in areas treated with heating pads and blankets.2 Other triggers such as frequent hot bathing, furniture, steam radiators, space heaters, and laptops also have been reported.3-6 Laptop-induced erythema ab igne is a diagnosis that has been reported in the last decade and its incidence likely will increase in the future.6
The clinical manifestations of erythema ab igne correlate with the frequency and duration of heat exposure. Acutely, a mild and transient erythema develops in the affected area. With chronic heat exposure, these areas subsequently develop a permanent reticulated hyperpigmented pattern and may eventually become atrophic.2,6 All body surfaces are at risk, but erythema ab igne classically involves the legs, lower back, and/or abdomen. Lesions typically are asymptomatic; however, burning and pruritus can be present.2,6 Bullous erythema ab igne, though rare, has been reported,7 suggesting a potential transition from erythema ab igne to burns.6
Biopsy is not recommended for diagnosis; however, the histopathologic changes of erythema ab igne include hyperkeratosis, interface dermatitis, epidermal atrophy with apoptotic keratinocytes, and melanin incontinence. Although this condition typically is benign, histologic findings could resemble actinic keratosis, suggesting that chronic changes induced by infrared thermal radiation may lead to squamous cell carcinoma or rarely Merkel cell carcinoma. The latency for developing carcinoma appears to extend 30 years, with a 30% tendency for recurrence or metastasis. Given the possibility of an increase in erythema ab igne in the pediatric population in the upcoming years, as displayed by our patient, and increasing laptop and electronic use in children and adolescents, it is important to be aware of this skin condition and the potential complications of it going undiagnosed.2,6
No specific therapy for erythema ab igne exists. Treatment is centered on eliminating exposure to the heat source. With appropriate removal, the reticulated hyperpigmented lesions will resolve, sometimes taking several months.
Differential diagnosis includes livedo reticularis, livedoid vasculopathy, and cutis marmorata. The reticulated purpuric lesions of livedo reticularis involving the extremities often mimic erythema ab igne's cutaneous morphology; however, livedo reticularis frequently is associated with conditions such as drug reactions, infections, thrombosis, and vasculitides,2 as opposed to erythema ab igne, which frequently is associated with conditions causing pain or decreased body temperature, thus necessitating use of heating devices, as seen in our patient. Livedoid vasculopathy is characterized by purpuric macules involving the lower legs and feet that progress to recurrent leg ulcers. Our patient's asymptomatic lesions and absence of ulcers excluded this diagnosis.8 Lastly, cutis marmorata, a congenital condition, is characterized by blue-violet vascular networks that often display ulceration and atrophy of the involved skin as well as hypertrophy or atrophy of the involved limb9; these clinical findings were not present in our patient and this diagnosis would not explain the relationship between the cutaneous lesions and heat exposure.
The Diagnosis: Erythema Ab Igne
Given the patient's reticulated hyperpigmented lesions in the setting of recent space heater use with heater closer to the more affected leg, erythema ab igne was diagnosed. Patient education was provided and moving the heater away from the lower extremities was advised.
Erythema ab igne first was described by German dermatologist Abraham Buschke as hitze melanose, meaning melanosis induced by heat. The classic skin findings were first observed on the lower legs of patients who worked in front of open fires or coal stoves.1 Over the years, new causes of erythema ab igne secondary to prolonged thermal radiation exposure have been reported.1 In the elderly, hospitalized, and chronic pain patients, erythema ab igne has been observed in areas treated with heating pads and blankets.2 Other triggers such as frequent hot bathing, furniture, steam radiators, space heaters, and laptops also have been reported.3-6 Laptop-induced erythema ab igne is a diagnosis that has been reported in the last decade and its incidence likely will increase in the future.6
The clinical manifestations of erythema ab igne correlate with the frequency and duration of heat exposure. Acutely, a mild and transient erythema develops in the affected area. With chronic heat exposure, these areas subsequently develop a permanent reticulated hyperpigmented pattern and may eventually become atrophic.2,6 All body surfaces are at risk, but erythema ab igne classically involves the legs, lower back, and/or abdomen. Lesions typically are asymptomatic; however, burning and pruritus can be present.2,6 Bullous erythema ab igne, though rare, has been reported,7 suggesting a potential transition from erythema ab igne to burns.6
Biopsy is not recommended for diagnosis; however, the histopathologic changes of erythema ab igne include hyperkeratosis, interface dermatitis, epidermal atrophy with apoptotic keratinocytes, and melanin incontinence. Although this condition typically is benign, histologic findings could resemble actinic keratosis, suggesting that chronic changes induced by infrared thermal radiation may lead to squamous cell carcinoma or rarely Merkel cell carcinoma. The latency for developing carcinoma appears to extend 30 years, with a 30% tendency for recurrence or metastasis. Given the possibility of an increase in erythema ab igne in the pediatric population in the upcoming years, as displayed by our patient, and increasing laptop and electronic use in children and adolescents, it is important to be aware of this skin condition and the potential complications of it going undiagnosed.2,6
No specific therapy for erythema ab igne exists. Treatment is centered on eliminating exposure to the heat source. With appropriate removal, the reticulated hyperpigmented lesions will resolve, sometimes taking several months.
Differential diagnosis includes livedo reticularis, livedoid vasculopathy, and cutis marmorata. The reticulated purpuric lesions of livedo reticularis involving the extremities often mimic erythema ab igne's cutaneous morphology; however, livedo reticularis frequently is associated with conditions such as drug reactions, infections, thrombosis, and vasculitides,2 as opposed to erythema ab igne, which frequently is associated with conditions causing pain or decreased body temperature, thus necessitating use of heating devices, as seen in our patient. Livedoid vasculopathy is characterized by purpuric macules involving the lower legs and feet that progress to recurrent leg ulcers. Our patient's asymptomatic lesions and absence of ulcers excluded this diagnosis.8 Lastly, cutis marmorata, a congenital condition, is characterized by blue-violet vascular networks that often display ulceration and atrophy of the involved skin as well as hypertrophy or atrophy of the involved limb9; these clinical findings were not present in our patient and this diagnosis would not explain the relationship between the cutaneous lesions and heat exposure.
- Nilic M, Adams BB. Erythema ab igne induced by a laptop computer. J Am Acad Dermatol. 2004;50:973-974.
- Riahi RR, Cohen PR, Robinson FW, et al. Erythema ab igne mimicking livedo reticularis. Int J Dermatol. 2010;49:1314-1317.
- Lin SJ, Hsu CJ, Chiu HC. Erythema ab igne caused by frequent hot bathing. Acta Derm Venereol. 2002;82:478-479.
- Meffert JJ, Davis BM. Furniture-induced erythema ab igne. J Am Acad Dermatol. 1996;34:516-517.
- Kligman LH, Kligman AM. Reflections on heat. Br J Dermatol. 1984;110:369-375.
- Arnold AW, Itin PH. Laptop computer−induced erythema ab igne in a child and review of the literature [published online October 4, 2010]. Pediatrics. 2010;126:e1227-e1230.
- Kokturk A, Kaya TI, Baz K, et al. Bullous erythema ab igne. Dermatol Online J. 2003;9:18.
- Khenifer S, Thomas L, Balme B, et al. Livedoid vasculopathy: thrombotic or inflammatory disease? Clin Exp Dermatol. 2009;35:693-698.
- Pernet C, Guillot B, Bigorre M, et al. Focal and atrophic cutis marmorata telangiectatica congenital. J Am Acad Dermatol. 2013;69:e268-e269.
- Nilic M, Adams BB. Erythema ab igne induced by a laptop computer. J Am Acad Dermatol. 2004;50:973-974.
- Riahi RR, Cohen PR, Robinson FW, et al. Erythema ab igne mimicking livedo reticularis. Int J Dermatol. 2010;49:1314-1317.
- Lin SJ, Hsu CJ, Chiu HC. Erythema ab igne caused by frequent hot bathing. Acta Derm Venereol. 2002;82:478-479.
- Meffert JJ, Davis BM. Furniture-induced erythema ab igne. J Am Acad Dermatol. 1996;34:516-517.
- Kligman LH, Kligman AM. Reflections on heat. Br J Dermatol. 1984;110:369-375.
- Arnold AW, Itin PH. Laptop computer−induced erythema ab igne in a child and review of the literature [published online October 4, 2010]. Pediatrics. 2010;126:e1227-e1230.
- Kokturk A, Kaya TI, Baz K, et al. Bullous erythema ab igne. Dermatol Online J. 2003;9:18.
- Khenifer S, Thomas L, Balme B, et al. Livedoid vasculopathy: thrombotic or inflammatory disease? Clin Exp Dermatol. 2009;35:693-698.
- Pernet C, Guillot B, Bigorre M, et al. Focal and atrophic cutis marmorata telangiectatica congenital. J Am Acad Dermatol. 2013;69:e268-e269.
A 13-year-old otherwise healthy adolescent girl presented to the pediatric dermatology clinic for evaluation of a rash on the legs. The patient noticed the rash 1 month prior to presentation. The rash initially involved the left shin and gradually spread to involve the shins bilaterally. The rash was asymptomatic with no pain, pruritus, or muscular asymmetry of the legs. She denied recent fevers, chills, or travel. The patient reported using a space heater daily that was directed at the legs, approximately 0.5 m away. Physical examination revealed a well-nourished adolescent girl in no acute distress with reticular hyperpigmentation of the lower extremities located on the left anterior shin and knee, with mild involvement of the right shin. The reticulated hyperpigmented areas were arranged in a rectangular distribution. Lower extremity musculoskeletal examination was symmetric.
