HPI: 52 year old African American female presented with 1-2 months of a painful red rash around the eyes, nose, and mouth as well as the posterior neck, buttock, and lower legs. She was recently given antibiotics from an urgent care without improvement. She denied history of a similar rash. She also endorsed several months of progressive 50 pound unintentional weight loss. She denied fevers, chills, SOB, chest pain, or nausea. The patient was admitted for severe malnutrition and further work up.
PMH/PSH: Hypertension, not on medication
Social History: Drinking 6 beers per day. Current smoker with 30 pack-year history. Denied illicit drug abuse.
Family History: Mother with HTN
Allergies: No known drug allergies
Medications: Recent script for Metronidazole 500mg tid for 3 days and Azithromycin 500mg daily for 3 days
Physical Exam: Erythematous, scaly, keratotic papules and plaques around eyes, nose, and mouth (Fig. 1). Lichenified plaque on the posterior neck (Fig. 2). Erythema, scale, and erosions on buttock and bilateral lower extremities (Figs. 3,4).
Imaging: CT scan of Chest/Abdomen/Pelvis showed diffuse body wall edema and ascites, without evidence of malignancy or metastatic disease.
Laboratory results: Zinc 0.18 (normal 0.66-1.10 mcg/ml). Plasma glucagon 65 (normal 0-80 pg/ml). Peri-anal HSV pcr swab positive. Hep C negative. HIV negative.
Hgb 7.0 with MCV 91.3. Sodium 132, Potassium 2.8, Creatinine 0.53, Calcium 7.6. Albumin 2.1, plasma protein 5.8. Phosphorus 2.9 (2.3-4.5 mg/dl). Magnesium 1.5 (1.4-2.5 mg/dl).
Click here for the Diagnosis.