The Bruiser from Cuba

Transcription

1 The Bruiser from Cuba J.A. Schneider, DO Medical Director, Adolescent Medicine Mobile Health Outreach St. Vincent Hospital - Jacksonville, FL CAPT, MC, USN (Ret) Asst. Professor, Division of Adolescent Medicine, University of Florida (Ret)

2 Mike O Log 7-year-old male transferred to Naval Hospital Portsmouth (Virginia) from Naval Hospital Guantanimo Bay, Cuba for evaluation of easy bruising History Mike had been perfectly well until 4 days prior to these pictures when he was taken to the pediatric clinic because new bruises were of concern to his mother.

3 Mike O Log ( continued ) History (continued) No bruising in the past; no nosebleeds Platelet count in Cuba was 45,000 with a normal CBC. BUT the platelet count was 245,000 with a normal CBC and normal indices in our laboratory Physical Examination Afebrile; normal vital signs Not ill-appearing active, well nourished, well developed

4 Mike O Log History (continued) The past medical history and review of systems is entirely non-contributory

5 Physical Exam: Bizarre linear hyperpigmentation without petecchiae nor purpura No hepatosplenomegaly

6 The total picture no bruising rather strangely discolored linear and whorled hyperpigmentation. The denuded area under his left areola looks like a burn!

7 Linear hyperpigmentation on Mike s forearms

8 Close-up of lesions on Mike s abdomen

9 Let s put this all together now... He doesn t have leukemia The bruising is bizarre.. like something was smeared on his skin The big question is, Could he have gotten into something / played with something that would react with his skin?

10 fingers palm Close-up of lesions on Mike s abdomen HEY!!! that looks like a hand print!!!

11 I don t want to leave you hanging the answer is...

12 Ask and ye shall find Mike and his buddies were playing with limes from the lime tree in his back yard. Mike was smearing the lime juice on his skin So, Mike has...

13 Phytophotodermatitis or Lime Disease

14 Phytophotodermatitis or Lime Disease Fucocoumarins (psoralens), present in limes that he played with, reacted with the sunlight causing a photosensitive reaction Fucocoumarins are present in a wide variety of plants

15 Plants containing Psoralens Celery Gas Plant Meadow grass Parsnip Limes Tomato Angelica Wild Angelica Cow Parsley Carrots Figs Oranges Bishop s Weed Hogweed Rue?? others

16 Now, let s take a look at another case of phytophotodermatitis that presented as a case of suspected child abuse... Phillip Buster was being evaluated for the sudden onset of unexplained burns. There was seemingly no explanation and the child protection team was called. However, the attending in the clinic asked the magic question...

17 Strange linear erythema on arms

18 Now, look again look very closely...it almost looks like fingerprints on Phillip s left side

19 Phillip as he presented in the clinic The magic question was, Had Phillip been playing with limes?

20 Are you kidding?, replied his mother. I was making Key-Lime pie and every few minutes he would run through the kitchen and I would pick him up and put him outside to play. He was driving me nuts!

21 The crime is reenacted by Mrs. Buster

22 The crime is reenacted by Mrs. Buster

23 Case closed another case of phytophotodermatitis

24 References Phytophotodermatitis mimicking superficial lymphangitis. Br J Dermatol 2000 May; 142(5):1069. Ahmed I; Charles-Holmes R Phytophotodermatitis associated with parsnip picking.j Accid Emerg Med 1999 Nov;16(6): Lutchman L; Inyang V; Hodgkinson D

25 References Phytophotodermatitis due to the application of citrus hystrix as a folk remedy. Br J Dermatol 1999 Apr;140(4):737-8 Koh D Phytophotodermatitis. Am J Contact Dermat 1999 Jun;10 (2):89-93 Bowers AG

26 References Phytophotodermatitis: the other "lime" disease. J Emerg Med 1999 Mar-Apr; 17(2):235-7 Weber IC; Davis CP; Greeson DM Phytophotodermatitis mimicking child abuse. J R Soc Med 1997 Oct; 90 (10): Hill PF; Pickford M; Parkhouse N

27 References Phytophotodermatitis. J Pediatr Health Care 1997 Mar-Apr;11(2):84, 97-8 Bosch JJ Blistering of the hands and forearms. Phytophotodermatitis. Arch Dermatol 1995 Jul;131 (7): 834-5, Webb JM; Brooke P

28 References Phytophotodermatitis: a visit to Margaritaville. Cutis 1993 Jan;51(1):41-2 Egan CL; Sterling G An outbreak of phytophotodermatitis due to celery. Int J Dermatol 1994 Feb;33 (2):116-8 Finkelstein E; Afek U; Gross E; Aharoni N; Rosenberg L; Halevy S

29 References Phytophotodermatitis due to figs. Cutis 1991 Aug;48(2):151-2 Watemberg N; Urkin Y Phytophotodermatitis simulating child abuse. Am J Dis Child 1985 Mar;139(3): Coffman K; Boyce WT; Hansen RC A nice review is at Emedicine.com overview