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28 - A Chilling Pain
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 91-92
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Summary
Chilling the skin of this five-year-old boy was like sticking a dagger into him. Contact with any cold object brought him unbearable pain. Even a moderately cool drink would make him vomit. It had been that way ever since birth, his parents told us. Our patient treated a cold object as the rest of us would treat an open flame. There was no family history of such a condition.
On examination this little boy was a happy healthy individual with perfectly normal skin. But when he was held down, his trust betrayed, to test his skin reaction to a tiny ice chip, he became a pathetic screaming child covered with tears and muscle spasms. The test site with the ice chip flared out four inches with bright red skin and local sweating. The edges of the erythema were irregular, as seen with blood vessel dilatation induced by local nerve paths. There was no hive. The redness and screaming remained for a full hour. Later, the skin was perfectly normal again.
Testing with tubes of water at varying temperatures showed that his reaction developed whenever the temperature was below 68°F. Hot water was tolerated normally, but being put in a cool room was tragic torture. His skin sensory system seemed normal with touch and pain responses being unremarkable.
We had never seen such a reaction to cold. As we reviewed our experience with cold as a cause of disease we remembered that we had seen hives develop in chilled skin.
56 - The Creeping Acne Cyst
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 171-173
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It seemed to be an ordinary case of acne. A nineteen-year-old boy had numerous blackheads and pimples, as well as small scars, evidence of former battles fought in his skin down through the adolescent years. We knew it was the H & H disease, due to hormones and heredity. The androgens were pumping up oil production in the sebaceous glands of the face, while at the same time blocking its flow to the surface. The blockage was produced by plugs of dead horny cells, seen as blackheads but known scientifically as comedones. The name derives from the Spanish word for worms and, indeed, as we press them out, they look like little black worms. The black color is not due to dirt, but simply comes from a darkening of the plug due to oxidation. Scrubbing won't remove them any more than sanding a board will remove a nail. Each comedo is deep in the pore of an oil gland. At the time we prescribed vitamin A in large doses to promote shedding of these stagnant cells. Now, we would have prescribed the vitamin A derivative, Accutane®.
Of particular note was a tender inflamed acne cyst on his left upper cheek. These cysts develop when bacteria, trapped by the closed pore, produce inflammatory changes with the accumulation of pus. When the plugged oil gland is unable to dump its product, it finally swells like a balloon until becoming so large that it bursts.
6 - Uncombable Hair
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 26-28
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“Funny hair” was the only diagnosis that had been made on a two-year-old boy. His mother said she had never been able to comb it. Indeed, the little lad's straw-colored hair stood straight out from his scalp and was totally noncompliant with the wishes of any comb. It was right out of the old German fairy-tale featuring “Struwel Peter.” Here was a boy whose hair was a mess (Strüwel), never once combed, looking as if electrostatic forces were in complete control. Indeed they were.
But why? Not only was the hair noncombable, but it came out in clumps on gentle pulling. It grew very slowly and was the same length as it was six months ago despite never having been cut. The hairs were fragile and thin, and broke when they were twisted. Reflected light gave the hairs a spangled appearance. The eyelashes, eyebrows, fingernails, toenails, and teeth were all normal. His parents and brother, as well as other relatives, had normal hair. He had always been in good health, except for two attacks of ear infection (otitis media).
Under the microscope the hairs appeared to be normal, showing no nodes, knots, rings, twists, or fractures. Ultraviolet light examination revealed no evidence of ringworm infection.
It was not the physical examination, nor the blood and urine studies, that made the diagnosis. It was the scanning electron microscope.
48 - A Crazy Rash
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 146-149
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A sixty-six-year-old woman came fully frightened. She had been told that her rash could be mycosis fungoides, a rare form of malignant lymphoma. The diagnosis had been made on the basis of skin biopsy findings.
She related to us her eighteen-month history of a scaly, mildly itchy eruption. It had begun on her breasts, spreading later to her back, abdomen, and thighs. At first her condition had been called parapsoriasis, but a second skin biopsy suggested that the problem had become malignant, converting the diagnosis to mycosis fungoides.
Treatments had included cortisone preparations, both internally and externally, antihistamines, and the avoidance of bathing (which magnifies itch). Nothing had helped. She still had large red scaly patches on her trunk and thighs. We felt she had the benign parapsoriasis, and not the dreaded mycosis fungoides, which insidiously leads to skin tumors and eventually spreads internally.
Since there is no known cause of parapsoriasis, it is labeled “idiopathic.” A century of looking for causes of parapsoriasis had yielded no answers. It would have remained that way in our patient, but for our detective work. Actually, nothing blunts a doctor's zest for studying a patient more than a dermatosis known to be idiopathic.
But nothing occurs without cause, and elimination of the cause spells cure for disease. We, therefore, always zestfully hunt for a cause. Our most successful maneuver has been to look for foods, bugs, and drugs that might be incriminated.
49 - Bald Spots
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 150-152
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“His scalp is showing” was the delicate phrasing of a ten-year-old boy's mother. We learned that three months ago he had developed three perfectly round areas of perfectly bald skin on the right side of his scalp. They were totally symptomless, and not inflamed, looking like totally normal skin. Around the edges we could see tiny short hairs that looked like exclamation points. These helped confirm the diagnosis of alopecia areata.
The hair had simply suddenly fallen out without a trace. This was not the hair loss of lupus erythematosus, which is inflammatory, or the hair loss of ringworm with its broken hairs. This was not the hair loss of trichotillomania where the child plucks out his own hairs in frustration, leaving a tell-tale stubble of very short hairs (too short to pull).
No, this was an autoimmune condition known as alopecia areata. Somehow, the body rejects the hairs without any sign of obvious inflammation. As the hair follicles stumble to recovery around the edges, short atrophic exclamation point hairs are produced, constricted at the base in a sputtering regeneration.
We did not need a skin biopsy for diagnosis, but we needed to study him for a cause. Although alopecia areata is classified as an autoimmune disease, and thus a rejection phenomenon, we know from experience that a focus of infection may trigger such hair loss. What was this boy's source of infection? We did not have to look far.
53 - The Smell of Burnt Toast
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 161-164
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“I don't have a skin problem … but I was told you might help. A few months ago I woke up smelling smoke. But there was no smoke and ever since then everything has smelled like burnt toast,” was our introduction to a seventy-one-year-old woman. She went on to explain that this perception of the aroma of burnt toast was continuous, twenty-four hours a day, week in and week out. It seriously depressed her appetite. She no longer enjoyed food, although her sense of taste was perfectly normal. She had already lost 10 pounds in weight.
It wasn't that she had lost the sense of smell, but instead was a case of misidentification of odors. Even as people are color blind, she was odor blind. All stimuli of smell evoked only the smell of burnt toast, including coffee, onions and cantaloupe. The more powerful the stimulus the more intense the odor of burnt toast. Her medical diagnosis was dysosmia, or as some prefer to call it, parosmia.
The diagnosis was easy, but what caused this sudden malfunction of an organ which, in its own way, is as exquisitely specialized as the eye? The organ of olfaction is located in a patch of specialized mucosa high in each nostril. It is truly remarkable, for there, totally hidden from view, are over 10 million separate bare nerve endings. They are actually outside the body, unlike any other nerve.
40 - Hardened Skin
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 124-125
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“My skin is turning hard and I've been told that nothing can be done,” said a seventy-four-year-old woman who had just moved to our area from the South. She had recently been carefully studied by a number of doctors during a five-day stay in a university hospital. They told her she had generalized morphea, a condition for which no treatment was known. Unlike them, we greeted her with great optimism. Surely, we could do something to stop the inexorable progress of the hardening of her skin. She did not have to be Lot's wife.
She had first noted the indurated firm areas on her chest, but they had extended in eight months to also involve her back and abdomen. Her skin felt tight and itchy. Last week her right calf also started to become involved with the firm slightly darkened patches, which now we could also detect on her right forearm and both elbows. The breasts were the worst areas, with very shiny hard skin. Her hands, feet and face were unaffected.
Her past history revealed she took no medications, had no allergies, neither smoked cigarettes nor drank alcohol, and had never had any prior skin disease. She had worked in a poultry plant dressing chickens for twenty years, but was now retired. We could elicit no history of skin trauma at her work or of any tick bite preceding the hardening of the skin.
44 - A New Light on Psoriasis
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 135-137
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His mother brought him in for light therapy. He was eight years old and for the past year had been going to a distant skin clinic for ultraviolet light treatments for his psoriasis. The trip demanded three hours of driving three times a week. His mother finally asked, “Isn't there somewhere nearer to my home I could go to for these light treatments?” And so, he had been brought to us requesting a series of late after school appointments on Monday, Wednesday, and Friday.
We examined her son. He had extensive psoriasis on his trunk, arms, and legs, which was responding well to the ultraviolet light treatments. But, as parents, we thought of the drain of three visits each week to the doctor, even if close by. We knew there could be another way. Our research had shed a new light on psoriasis.
We explained to the mother that psoriasis has a hereditary background, which we could not alter. We explained that the silvery white scales her son shed everyday were dead flakes of his outermost skin, the epidermis. Normally, our skin sheds this dead stratum corneum invisibly because the particles are so small. They rub off in the bath or on the clothing without notice. But, in psoriasis, the epidermis is growing 10 times faster than normal, resulting in big thick white scales. The secret of treatment is to slow down the rapid division of the cells.
26 - Hot Flashes and Cold Cream
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 85-87
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“I've been having hot flashes for three years and no one knows why,” stated a thirty-one-year-old secretary. It soon developed that not only did she get sudden flushes, but they were accompanied by both hives and headaches during severe attacks. She had noted that both the flushing and hives began about an hour after arising, and continued to develop throughout the day and evening, vanishing while she slept. The flushing then began again the next morning as a gradual wave of warmth spreading over her head, neck, and shoulders. The hives were small and scattered over the trunk.
Complete gynecologic and endocrinologic workups were to no avail. She was taking no medications and denied chemical exposures at work. Furthermore, the flushing, hives and headaches did not remit during vacations. It was not occupational.
Examination at her first visit found our patient to be healthy, but her face, neck and shoulders were flushed and warm. There were isolated small wheals, less than a half inch in diameter, scattered over these areas as well as her trunk. Individual hives faded in one to two hours, even as new ones developed. Firm stroking of her skin produced a linear hive, the cardinal sign of dermographism, a condition known as “skin writing.” More importantly, it told us that the cause was something circulating in her blood. It could be a food or something she was inhaling.
55 - The Mysterious Treatment
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 169-170
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“What can I do? What can I do?” came the sobbing voice over the telephone. It was a former patient of ours. “What can I do?” she continued, “My mother has pemphigus with blisters all over her body. Her doctors tell her she will die if she doesn't have treatment.” “So?” we replied. “But, my mother won't accept any treatment, since it's against her religious beliefs. Last year she had a blood clot and lost her leg because she would not allow any treatment. What can I do?” We tried to calm the daughter, telling her we would see what we could do. “Tell your mother I would like to see her as a friend, not as a patient. Just bring her over for a chat.”
The next day in came the daughter with her mother. As we sat in the consultation room, the tears were rolling down the daughter's cheeks. And clear fluid was dripping down the mother's leg from large open blisters. Indeed, the dye from her purple shoes was being leached out onto our carpet.
The mystery was, how to treat this little old lady so she could hold onto life and her religious beliefs. The epiphany came in a flash as we began talking about the dye on our carpet. It was then that we saw a magic carpet of therapy. We said to the mother, “We see that your daughter is very sick. May we help her?” The mother gave a wan assent.
20 - Hormone Blisters
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 68-70
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Sometimes despair over a skin disease that fails to yield to treatment can lead to suicide. We have seen that tragedy twice – once in a young man with hair loss and the other in a boy with acne. And it almost happened with this patient. For five long years, a twenty-seven-year-old woman had suffered an extremely severe itch associated with small water blisters on her arms, legs and trunk. They came in groups in arciform configuration. Many of the soft tops had been scratched off, leaving areas of redness, crusting, and scars where she had dug the skin away to relieve her itch. The skin was both hyperpigmented and depigmented.
She stated that it all began a week after the birth of her second child. She was told it was due to sunlight sensitivity, and, indeed, it slowly faded as she dutifully avoided the sun. Two years later it recurred explosively after the birth of her third child and then had remained unchecked for the past three years. She has wandered from doctor to doctor, who have wandered from diagnosis to diagnosis, and from treatment to treatment. She has had numerous biopsies and as many diagnoses. Steroids, antibiotics, antihistaminics, and sedatives were all of no avail. She was told it was due to nerves, that it was due to an allergy to gluten in wheat, and that it was a virus infection. AIDS had not made its entrance or it, too, would have been considered.
24 - Fiery Red Legs
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 80-82
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“Look at my legs” said a thirty-nine-year-old woman. We looked and in a split second knew the diagnosis. It was one of the augenblick diagnoses a dermatologist makes in 1/25 of a second when a recognizable pattern of skin disease is present. For these diagnoses, it is better to pass by a dermatologist in the hall than spend hours in a general physicians office or have a sheath of laboratory reports. Specialism has its place. A specialist does not have to re-invent the disease.
Yes, she had essential progressive telangiectasia, made up of innumerable tiny dilated blood vessels extending up her legs. We do not know the cause, but have seen them cover the entire body, becoming generalized. No, the mystery here was not the diagnosis, but why did she have it, and what could we do about it?
First, as always, there is the history. Seven years before she first noted a red patch of small dilated blood vessels over her right foot. It seemed innocent enough, perhaps due to a tight fitting shoe. But soon it appeared on the other foot, also due to a tight shoe? Then she became alarmed as this fiery red eruption began to climb up her legs. True, it was not painful, itchy, or bleeding, and there were no black and blue marks. No one else in the family had anything like it.
The dilated (telangiectatic) vessels had reached her thighs by the time she reached our office.
47 - The Sleeper
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 143-145
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“My skin is becoming stiff,” recounted a forty-three-year-old woman. For the past few months she had noted a woody firmness of the skin on her thighs and there were red patches on her shins which also felt stiff. Her face, hands, and feet were normal. She had always been in good health and blood studies showed only a mild increase in her eosinophilic white cells.
Clinically, we felt she had the hardened skin patches of morphea, the localized form of scleroderma. We attempted to ferret out a cause, with no luck. She was taking no medications. There had been no tick bites or even a leech bite, which had caused morphea in one of our patients. She denied infections or exposure to organic chemicals, such as polyvinyl chloride, known to harden the skin. She also did not take the drug, methysergide, notorious for its ability to indurate connective tissue. She had never had silicone breast implants, which might leak and induce sclerotic skin.
We tried both cortisone and antibiotic therapy without success, as well as topical emollients which were likewise without effect. We were still searching for a cause when the patient came in with the answer and with an apology. She had found the reason in the newspaper, learning that the FDA had banned the sale of the amino acid, tryptophan. This over-the-counter compound used by thousands to combat insomnia and depression was now linked to hundreds of cases of hardening of the skin.
30 - The Premenstrual Purple Chin
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 95-96
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The mother gave the history that for three years now her teenage daughter had been developing a purplish discoloration of her chin approximately three to five times a year. But now, the episodes were occurring with increasing frequency. The purple chin had appeared just prior to her last three menses. The attacks always came during school hours, and the color gradually faded during the following week. The skin always returned completely to normal.
We turned to the girl. What could she tell us? She described her chin as suddenly turning purple and becoming tender and painful. Her lips became swollen at the same time. Later, her chin was itchy. Steroid therapy, both orally and locally, had given no help. The attacks continued to come.
The daughter was a healthy thirteen year old. All of her blood tests were normal, and when we examined her nothing could be seen on the chin. We asked her to return during her next attack. Three weeks later, just before her menses, her chin suddenly became purple. We saw her five hours later, noting her chin to be diffusely discolored with a light purple color along with some dilated small blood vessels.
The premenstrual flare led us to believe she had a sensitivity to her own female hormones. We knew that progesterone, made by the ovary, reached its highest blood levels just before the menses.
43 - The Worm from Outer Space
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 133-134
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“See my worm,” begged a twenty-nine-year-old man. We were the fifth dermatologist that week he had consulted in his frantic search for medical help. All of the others had referred him to psychiatrists, but he knew that was wrong and he was going to prove it to me. He knew he had been infected by a worm from outer space, and was desperate for a cure, but no one would believe him.
As he unrolled the gauze from his left wrist we did indeed see “the worm.” It was there in the skin at the flexure of his wrist, neatly surgically exposed. It was long, narrow, white, glistening and warm, recognizable as a tendon!
We marveled and he went on to explain that he had felt the worm moving in his skin. He quickly described how he had gone to the local surgical supply house yesterday and purchased a scalpel, forceps, and probes. At 5:00 a.m. that morning he had operated, skillfully avoiding the major arteries and veins of his wrist. Now he had proof, and, fortunately, our office staff had given him an emergency appointment.
As we listened to the story, told by this man with piercing eyes, we realized he was a special type of orphan patient. He was not orphaned by physician indifference, physician ignorance, or physician disbelief. He had been orphaned by his own noncompliance. But, why should he see a psychiatrist? Did these doctors … did we … think he was crazy?
Frontmatter
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp i-vi
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46 - The Emergency Room Itch
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 140-142
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A seventy-year-old woman was supposed to see us on a Thursday afternoon. She was coming a great distance from a nursing home and our staff had been told she had had a rash over her entire body for the two years she had been in that home. They felt it was a drug eruption and hoped we could help.
The patient failed to show for her appointment, but the following Monday morning we were called to see her in the hospital. She had been brought by ambulance four days before for emergency surgery in the middle of the night, engendered by a blood clot in her left leg.
On examination we saw a woman clawing her inflamed red scaly skin, complaining of a terrible itch: “I've had it for years. Do something!” Between her fingers we saw tiny blisters, and on her fingers there were several thread-like burrows. She had scabies, the highly contagious “seven year itch.” We proved it by finding the Acarus scabiei itch mite on scrapings. Yes, we found out that she did not have a drug rash, but scabies. And as soon as we learned it, so did the ambulance driver and his two assistants, six nurses in the emergency room, and another nine floor nurses, as well as the vascular surgeon and three of his operating room nurses. All twenty-two were now itching, because they caught scabies from their contact with her.
42 - Swollen Lips
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 129-132
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“My hair is falling out” was the complaint of a forty-five-year-old woman. This is always a difficult challenge for us. First, is the loss real or imagined? There are at least 100,000 hairs on the scalp, and with aging we lose them insidiously. And in the case of women with bouffant coiffuring, 80,000 of these can be lost before the thinning is obvious to anyone but the patient. We have no instrumentation to accurately count the hairs. Assessment is therefore crude, unlike the precision we achieve in counting the invisible red cells in a drop of blood. The number of hairs on sample areas of skin can be counted, but is so painstaking a process as to be impractical, except in a research study of the modern hair growth stimulants, Rogaine® (minoxidil) and Propecia® (finasteride). She could and did count the hairs combed out each day. These far exceeded the normal average daily hair loss of 75 to 100.
We concluded that this patient's hair loss was real. Now came the search for why. The hair was not breaking off, nor did it have loose roots. Her root strength was good when we tugged on her hair. Under the microscope her hair appeared normal. Was it simply aging? Every single one of us no longer has the hair count of our youth. However, that hair loss is gradual and inapparent, whereas this woman knew that her hair had been thinning for only the past few months.
51 - The Abacus Tumor
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 156-157
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“What is this thing that moves up and down my arm?” asked a seventy-six-year-old retiree. He demonstrated a little lump under the skin of his left forearm. He moved it first down near his wrist and then way back up his arm. It could travel about 8 inches, just like an abacus bead. He told us he had played with it for about six months. It was a painless firm lump, about a half inch in diameter. There was no sign of inflammation. His health was excellent.
We were totally intrigued, having never seen a mobile tumor. We felt that it must be a foreign object, but he denied any history of bullet or shrapnel wounds. He had no knowledge of glass having penetrated his skin. We thought of a patient of ours from whom we extracted a six inch plant stem from her foot. She had been hiking in Scotland in open sandals and had no knowledge of how the stem had gotten into her skin. Surely, this man's tumor must be an inert foreign mass. Or could it be a parasitic larva that had died in the skin and become enclosed in a fibrous movable caul? Could it be a strange rheumatoid nodule? He did have arthritis of his left wrist.
We knew this mystery would be easy to solve. There was no need for a dazzling differential diagnostic list of twenty diseases. It was a vignette á clef where biopsy was the key.
39 - The Minister's Hives
- Walter B. Shelley, Medical University of Ohio, E. Dorinda Shelley, Medical University of Ohio
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- Consultations in Dermatology
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- 23 November 2009
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- 13 February 2006, pp 121-123
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It seemed simple enough at first. He was a forty-year-old minister who came to us suffering from hives for the past five years. A glance at his palms and then his soles showed them to be dry and scaling. “Yes, my hands have been dry for nearly twenty years and my feet for even ten years longer.” Our assumption that this was a fungal infection was confirmed by microscopic examination of the scales. It all seemed so simple. Obviously, he had become allergic to these fungi and developed hives whenever the dead fungal elements entered his blood. All we had to do was treat his hands and feet and the hives would go away. Well, griseofulvin did completely cure his decades of scaly palms and soles, but the hives paid no attention. They kept right on coming.
We then found he had developed hives when given penicillin, and thought perhaps this tied in with penicillin coming from a mold similar to the fungus on his hands and feet, which might also have produced a penicillin-like product. But his fungus infection was gone, and he took no penicillin. His case was becoming complex. He had seen an allergist who, by scratch testing, showed he was allergic to eight different foods. However, a strict elimination diet for two months did not help.
Rounding up the usual suspects for hives was to no avail. He took no drugs. His dental, sinus and chest films were normal. But back to his skin tests.