This is an easy and classic question that you can also apply to daily clinical practice. Hypophonesis in a hemithorax + tympanism = pneumothorax. If there is dullness on percussion: hemothorax. In either case, in case of hypophonesis of a hemithorax in a severe and unstable polytraumatized patient: thoracic drainage (if possible, large caliber if placed in a hospital environment, since although the predominant lesion is pneumothorax, a hemothorax component can be found which, in case of placing a fine drainage, could obstruct it).

35-year-old male, transferred to the emergency department after a traffic accident. On admission, a Glasgow scale score of 15, blood pressure of 140/90 mmHg, respiratory rate of 35 rpm and heart rate of 110 bpm, with a baseline oxygen saturation of 91%. On examination there is right thoracic hypophonesis and tympanism on percussion.What is the presumptive diagnosis? :

A shocking bike accident.

CLINICAL INTRODUCTION: A man in his late 40s presented with severe chest pain and progressive dyspnoea after hitting a tree at high speed during a bike ride in the woods. On admission, the patient appeared agitated, pale and sweaty. Core temperature was 35.5°C, respiratory rate 35/min and blood pressure 90/50 mm Hg with a regular pulse at 110 beats/min. Physical examination revealed multiple sternal bruises, distended jugular veins and muffled heart sounds (figure 1A). Lactate level was 4.4 mmol/L (normal <2.0 mmol/L) and high-sensitivity cardiac troponin T 0.142 mcg/L (normal <0.005 mcg/L). An ECG and a total body CT scan were performed (figure 1B,C).heartjnl;104/20/1706/F1F1F1Figure 1(A) Multiple sternal bruises. (B) ECG on admission. (C) Thoracic CT. QUESTION  WHAT IS THE MOST LIKELY DIAGNOSIS?: Inferior myocardial infarction with right ventricular involvement.Cardiac contusion with tamponade.Commotio cordis.Aortic laceration.

[Factors affecting mortality in blunt thoracic trauma].

Blunt thoracic trauma is usually associated with extra-thoracic injuries, but the effect of blunt thoracic trauma on mortality is not known. Patients with blunt thoracic trauma were evaluated with regard to clinical findings and factors affecting mortality. There were 76 patients (37.2±15 years) in the study group. Traffic accidents (63%) were the most common cause of trauma. Pneumothorax (54%), rib fracture (42%), hemothorax (22%) and lung contusion (22%) were common thoracic injuries. Extra-thoracic injuries were most commonly seen in the extremities (46%) and abdomen (40%). Glasgow Coma, Injury Severity and Revised Trauma Scores were 14±2.6, 19±13 and 7.4±1.5, respectively. Non-operative management was effective in 37 (48.7%) patients, tube thoracotomy and thoracotomy were performed in 37 (48.7%) and 2 (2.6%) patients, respectively. Mortality rate was 10.5%. Systolic blood pressure lower than 90 mmHg and superficial and apneic respiration at the first admission, and values of trauma scoring systems were significantly associated with mortality (p<0.05). The effect of thoracic trauma on mortality with regard to thoracic pathology is not shown, although it is usually associated with extra-thoracic injuries. There was a close relationship between the pattern of respiration, values of systolic blood pressure and trauma scoring systems, and mortality. Non-operative management and tube thoracotomy were effective in most of the cases.

Blunt rupture of the thoracic duct after severe thoracic trauma.

A 53-year-old man was admitted to our trauma center after sustaining thoracoabdominal injuries, secondary to a rear-end motor vehicle collision. As he stepped out of his vehicle, he was struck by a tractor trailer at 55 mph. The following were the initial vital signs on his arrival: heart rate 140 beats/min, blood pressure 142/80 mm Hg, respiratory rate 28 breaths/min, temperature 36.8°C, and oxygen saturation 93%. The Glasgow Coma Scale score was 15 and the Injury Severity Score was 59. He was evaluated and resuscitated per the advanced trauma life support protocols. The focused assessment with sonography for trauma examination was negative. Initial findings included bilateral chest wall and thoracic spine tenderness, subcutaneous emphysema in the chest and neck, and an unstable pelvis. He required bilateral chest tubes and a pelvic binder. CT imaging revealed a left temporal epidural hematoma, multiple facial fractures, a sternal fracture, a left scapula fracture, acromioclavicular fractures, bilateral hemopneumothoraces, pulmonary contusions, extensive pneumomediastinum compressing the right atrium, multiple rib fractures (2-10 on the left with a flail segment and 2-8 on the right) (figure 1), an unstable open-book pelvic fracture which included bilateral superior and inferior pubic rami fractures, sacral and left iliac wing fractures, and symphysis pubis diastasis.Figure 1Three-dimensional CT scan reconstruction demonstrating left-sided flail chest.The patient developed hypotension and severe respiratory distress, and was intubated. ECG revealed no dysrhythmias. Echocardiogram revealed significant left ventricular wall dysfunction consistent with myocardial contusion and right atrial compression. His troponins were also significantly elevated. He required significant resuscitation with crystalloids, blood products and vasopressors. He underwent bronchoscopy, esophagram and upper endoscopy to exclude tracheoesophageal injury, and these were negative. On hospital day 2, the patient was hemodynamically stable, and pressors were discontinued. His pelvic fractures were repaired using external fixation and sacral screws. Given his extensive left flail chest, he underwent reconstruction of his left chest wall on hospital day 5. Open reduction and internal fixation of his left ribs, 3 to 6 anteriorly and 4 to 7 posteriorly, with titanium plates was performed (figure 2). He had an epidural catheter inserted for analgesia. On postoperative day 2 after chest wall reconstruction, the patient was extubated and resumed enteral feeds. Overnight, the output from the left-sided chest tube changed from serosanguinous to milky. A sample was sent for triglycerides and lymphocyte counts confirming the diagnosis of chylothorax. His chest tube output increased to approximately 2000 mL/day. A lymphangiogram was performed with Lipiodol to diagnose the location of the chylous leak. It revealed contrast extravasation at the level of T3 to T4. An MRI was also performed to better define the anatomic course of the thoracic duct.Figure 2Postoperative chest X-ray demonstrating left chest wall reconstruction. Conservative management: placing the patient nulla per os (NPO), and starting total parenteral nutrition (TPN), octreotide and midodrine.Thoracic duct embolization by interventional radiology.CT-guided thoracic duct disruption.Thoracotomy with thoracic duct ligation.

Case 1/2013: 69-year-old male patient with sudden back and lower right limb pain and shock.

The patient, MSM, a 69-year-old man, sought medical care due to left dorsal and right lower limb pain. The chest x-ray showed mediastinal enlargement. He was undergoing examination when he lost consciousness and went into shock. Subcutaneous emphysema was observed in the left hemithorax, as well as abolition of breath sounds at auscultation. Tracheal intubation was performed with draining of blood-tinged fluid from the left hemithorax. Echocardiography showed left ventricle with 44/29 mm; septum, 12 mm; posterior wall, 13 mm; mild aortic root dilation, dissection of the lamina and periaortic hematoma. The valves and pericardium were normal. The patient was transferred to Instituto do Coraçao - InCor. Physical examination (21 Oct 2004: 10:45) showed that the patient was sedated with tracheal intubation, pale, heart rate at 90 bpm, blood pressure 130 x 80 mmHg, bloody drainage in the chest tube. Electrocardiogram - frequency 90 bpm, sinus rhythm, low voltage in the frontal plane and decreased voltage in left leads (Fig. 1). Computed tomography showed bilateral subcutaneous emphysema, thoracic aorta with inaccurate borders in its descending portion (from the subclavian artery to the middle portion), collapsed left lung and extensive collection of hematic characteristics in same hemithorax and middle and posterior mediastinum. Small right pneumothorax; small right pleural effusion with underlying parenchymal alterations. The analysis of the heart was impaired by the presence of hemothorax. While undergoing computed tomography, the patient showed no pulse, mydriasis, with asystole unresponsive to resuscitation and died (21 Oct 2011; 15:00 h).

[Blunt thoracic injury].

Of 161 patients with blunt thoracic injury, 135 were male (83.9%) and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motor cycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign.

Advanced trauma life support

Breathing and ventilation The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion and Cardiac Tamponade. Flail chest, tracheal deviation, penetrating injuries and bruising can be recognized by inspection. Subcutaneous emphysema can be recognized by palpation. Tension Pneumothorax and Haemothorax can be recognized by percussion and auscultation.

Attention: Cardiac contusion.

The objective of the study is to investigate diagnostic and clinical processes performed for cardiac contusion in patients with blunt thoracic trauma. This study was conducted retrospectively on 65 patients admitted with isolated blunt thoracic trauma to the Emergency Medicine Department. The CT images, the cardiac enzyme levels, the periodic 4-h follow-up electrocardiography (ECGs) in the emer-gency department, and the results of echocardiography, performed at admission and when required according to the clinical status, were investigated. The 1-h and 4-h high-sensitivity troponin I levels were studied, and values above 0.04 ng/ml were considered as positive. Sixty-five patients with isolated thoracic trauma were included in the study, 23 (35.38%) had pulmonary and cardiac contu-sions both. In 23 (35.38%) patients, pulmonary contusion had been present, and cardiac contusion had not been identified at the initial evaluation. However, during clinical follow-up, troponin became positive, dysrhythmia developed, and the trauma affected the heart in four of these patients. In six (9.24%) patients, cardiac contusion was identified without pulmonary contusion. In 13 (20%) patients, no cardiac or pulmonary contusion was identified. troponin elevation was detected in 10 patients without a diagnosis of cardiac contusion who had a pulmonary contusion, hemothorax, and/or pneumothorax at the time of hospital admission and then with normal troponin levels at 4-h control. We found that there was a statistical agreement between cardiac contusion and troponin-ECG results at 4th h. We advise that all blunt thoracic trauma patients should be screened for cardiac contusion by continuous ECG monitoring and troponin levels.

Blunt traumatic cardiac rupture. A 5-year experience.

Blunt traumatic cardiac rupture is associated with a high rate of mortality. A review of the computerized trauma registry (1983 to 1988) identified 32 patients with this injury (ages 19 to 65 years; mean age, 39.5 years; 21 men and 11 women). Twenty-one patients (65.6%) were injured in vehicular crashes, 3 (9.4%) in pedestrian accidents, 3 (9.4%) in motorcycle accidents; 3 (9.4%) sustained crush injury; 1 (3.1%) was injured by a fall; and 1 (3.1%) was kicked in the chest by a horse. Anatomic injuries included right atrial rupture (13[40.6%]), left atrial rupture (8 [25%]), right ventricular rupture (10[31.3%]), left ventricular rupture (4[12.5%]), and rupture of two cardiac chambers (3 [9.4%]). Diagnosis was made by thoracotomy in all 20 patients presenting in cardiac arrest. In the remaining 12 patients, the diagnosis was established in seven by emergency left anterolateral thoracotomy and in five by subxyphoid pericardial window. Seven of these 12 patients (58.3%) had clinical cardiac tamponade and significant upper torso cyanosis. The mean Injury Severity Score (ISS), Trauma Score (TS), and Glasgow Coma Scale (GCS) score were 33.8, 13.2, and 14.3, respectively, among survivors and 51.5, 8.3, and 7.0 for nonsurvivors. The overall mortality rate was 81.3% (26 of 32 patients), the only survivors being those presenting with vital signs (6 of 12 patients [50%]). All patients with rupture of two cardiac chambers or with ventricular rupture died. The mortality rate from myocardial rupture is very high. Rapid prehospital transportation, a high index of suspicion, and prompt surgical intervention contribute to survival in these patients.

[Penetrating thoracic injury].

To clarify the clinical aspects of penetrating thoracic injury. Eighteen patients with penetrating thoracic injury treated from 1987 to 2005 were evaluated. There were 13 men and 5 women. The age distribution was 8 to 69 years, with an average of 36.7 years. There were 14 patients with stab wound and 4 with impalement injury. Five patients with stab wound were those who attempted suicide. In 4 patients with impalement injuries, the cause was fall in 2, traffic accident in 1 and sports injury in 1. The calculated injury severity score (ISS) was over 15 in 4 patients, 6 to 14 in 12, and under 5 in 2. Thoracotomy was performed in 2 patients with cardiac tamponade, 3 with massive hemothorax and 1 with an impalement injury caused by an iron bar. All of them were rescued and got well. In the other cases, after cleansing and debridement, the wound was closed and thoracic drainage was performed. Only 1 patient with cardiac arrest on arrival died within 24 hours after reviving. Emergent thoracotomy is indicated for patients with massive bleeding including shock, continuous air leakage and cardiac tamponade. Since cardiac arrest is difficult to cure, appropriate cooperation with the rescue team is necessary to avoid preventable trauma death.

Traumatic asphyxia

Traumatic asphyxia, or Perthes's syndrome, is a medical emergency caused by an intense compression of the thoracic cavity, causing venous back-flow from the right side of the heart into the veins of the neck and the brain. Signs and symptoms Traumatic asphyxia is characterized by cyanosis in the upper extremities, neck, and head as well as petechiae in the conjunctiva. Patients can also display jugular venous distention and facial edema. Associated injuries include pulmonary contusion, myocardial contusion, hemo/pneumothorax, and broken ribs. Causes Traumatic asphyxia occurs when a powerful compressive force is applied to the thoracic cavity. This is most often seen in motor vehicle accidents, as well as industrial and farming accidents. However, it can be present anytime a significant pressure is applied to the thorax.

Left atrial appendage rupture: A rare complication of right-sided haemothorax: A case report.

Cardiac injury accounts for less than 10 % of all traumas and it is a fatal condition associated with cardiac tamponade or massive haemothorax, which requires immediate intervention, such as resuscitative thoracotomy. However, in case of haemothorax without the findings suggestive of cardiac damage such as pericardial effusion, it is difficult to determine the complications of cardiac injury, because injury of the lung or intercostal arteries is usually considered first. We describe a rare case of left atrial appendage rupture with a right-sided massive haemothorax with slight cardiac effusion. A 47-year-old man with no significant medical history was transferred to our emergency department after crashing his motorcycle into a car. A right resuscitative thoracotomy for massive haemothorax was performed, followed by hilarious clamping and pericardial drainage. We found continuous bleeding from a right dorsal pericardial injury which indicated cardiac injury. Soon after the patient was referred to the operating room, left atrial appendage rupture was found, and ligated. The postoperative course was uneventful, and he was discharged on 15th postoperative day without complication. Left atrial appendage rupture is caused by a direct external force to the left atrium, so the pericardial injury is usually ipsilateral to the left side of the pericardium, resulting in perforation of the left thoracic cavity. Therefore, left atrial appendage rupture with a right-sided massive haemothorax is rare. In addition, when a cardiac injury is associated with a pericardial injury, most of the pericardial effusion drains into the thoracic cavity, resulting in a small amount of pericardial effusion, which make it difficult to recognize the cardiac injury. In conclusion, in blunt trauma, even in the case of a right-sided haemothorax, the possibility of cardiac injury in addition to pulmonary contusion should be considered and explored, because cardiac injury could be fatal.

Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report.

Traumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade. A 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot. Although the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient's life-threatening condition. A prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space.

Transmediastinal gunshot wound

Unstable patients The criteria to define a patient as stable or unstable could have variations from institution to institution. For example, Burack et al. used a list of 6 criteria in his paper that defined an unstable hemodynamic state: Traumatic cardiac arrest or near arrest and an EDT Cardiac tamponade Persistent ATLS class III shock despite fluid resuscitation (blood loss 1500–2000 mL, pulse rate greater than 120, blood pressure decreased) Chest tube output greater than 1500 mL of blood on insertion Chest tube output greater than 500 mL/hour for the initial hour Massive hemothorax after chest tube drainage One common criteria found in literature is a sustained systolic blood pressure of less than 100 mmHg, but this can be an oversimplification. Patients with clinical evidence of possible TMGSW that are considered unstable receive no further evaluation and are taken to surgery immediately. Management

Traumatic cardiac arrest

Hemothorax Hemothorax occurs when injury to the chest results in bleeding into the thoracic cavity. Similar to tension pneumothorax, increasing pressure prevents the return of blood from circulation to the heart. Cardiac tamponade In the setting of trauma, cardiac tamponade results from an acute pericardial effusion, the accumulation of blood within the sac that surrounds the heart. As this sac is filled with fluid, the pressure on the heart is increased, and the chambers of the heart are unable to fill with blood. Hypoxia Inability to maintain oxygenation in trauma patients may be a result of airway compromise due to mechanical injury or obstruction or due to loss of the respiratory drive from cervical spine or peripheral nerve injury. These conditions result in the hypoxia that may lead to cardiac arrest. Signs and symptoms

[2 cases of the tension pneumopericardium following blunt chest trauma resulting in the cardiac tamponade].

A 63-year-old man (case 1) was brought to our emergency unit following a high speed collision. He developed fatal cardiopulmonary arrest shortly after arrival despite resuscitation efforts. Tension pneumopericardium was revealed by chest X-ray and CT examination. An 18-year-old man (case 2) was admitted after a motorcycle accident. Pneumopericardium was noted on admission chest X-ray and CT examination. He developed cardiac tamponade after the examination. He was intubated and mechanically ventilated after the subxiphoid pericardial drainage. Pneumopericardium following blunt chest trauma is realized with tracheobronchial, pulmonary or esophageal injury. The clinical significance of pneumopericardium is the development of tension pneumopericardium resulting into cardiac tamponade. In a patient with traumatic pneumopericardium who requires mechanical ventilatory support, continuous pericardial drainage should be considered. In addition, tension pneumopericardium may occur in patients with breathing spontaneously as in our cases. In these cases, careful observation and immediate subxiphoid pericardial drainage are required.

[Blunt trauma to the intrapericardial inferior vena cava with concomitant rupture of the pericardium].

We report a rare case of blunt trauma to the intrapericardial inferior vena cava with concomitant rupture of the pericardium, which was successfully managed by surgical treatment. A 77-year-old male was transferred to our hospital for treatment of trauma by a traffic accident. The patient presented with the sign of shock and there were no external injuries. After admission, right-sided traumatic hemothorax and left-sided traumatic pneumothorax were drained with chest tubes. Although an echocardiography and chest computed tomography (CT) demonstrated no pericardial fluid collection and cardiovascular injuries, his blood pressure dropped suddenly with massive hemorrhage from right thoracic cavity after starting continuous suction drainage of bilateral chest tubes. Thus, we decided to perform emergency operation, while assuming that cardiovascular injuries were the source of the bleeding. A right-sided thoracotomy revealed that a small laceration of intrapericardial inferior vena cava with the pericardial tear was the site of the bleeding. Repair for that injury was done with interrupted sutures without cardiopulmonary bypass. He recovered gradually, and moved to department of orthopaedic surgery in a stable condition on the 25th hospital day.

[Aortic rupture after blunt chest trauma. Rapid diagnosis using transesophageal echocardiography when radiographic and computed tomographic findings are unclear].

A 37-year-old woman who was not wearing a seat-belt while driving a car had a head-on collision at 70 km/h. On arrival of the emergency physician she was awake and responsive but complained of pain with bruising over the sternum and the epigastrium. Pressure on the sternum was painful. Arterial pressure was 95/60 mm Hg, heart rate 112/min. On admission the heart sounds were unremarkable and peripheral pulses normal. Vesicular sounds were heard over both lungs. In addition to multiple facial abrasions voluntary movements were impaired and the right knee-joint was swollen. The ECG showed sinus tachycardia (103 beats/min) with left axis deviation, but was otherwise unremarkable. Initially the haemoglobin was 12.6 g/dl with normal white cell and platelet counts. Clotting tests, serum transaminases, creatine kinase, lactate dehydrogenase and other routine laboratory tests were within normal limits. Because the haemoglobin level had fallen to 7.7 g/dl within the first 4 hours erythrocytes concentrate was infused. The chest radiogram and subsequent computed tomography showed a mediastinal and paraaortic haematoma of unclear origin. Transoesophageal echocardiography (TEE) demonstrated rupture of the descending aorta with free floating intraluminal parts of the intima in the isthmal region, just distal to the origin of the left subclavian artery, which was not occluded. Colour Doppler echocardiography revealed abnormal flow into mediastinal and paraaortic tissues. At operation the echocardiographic findings were confirmed and part of the descending aorta was replaced by a 3 cm dacron tube during an aortic crossclamping time of 37 min. The patient was discharged after a postoperative stay of average length, during which her other injuries were treated. After blunt thoracic or deceleration trauma earliest possible TEE is indicated, because it can at once provide details of extent and degree of injury to heart and/or aorta.

An evidence-based approach to emergency ultrasound.

Paramedics bring into the ED an elderly man who is complaining of right-sided chest and abdominal pain. Earlier this morning, a friend had arrived at the patient's home and found him on the floor at the bottom of the stairs. The patient is in pain, somewhat altered, and unable to provide further details about what happened. After numerous attempts, the paramedics were only able to place a 22-gauge peripheral line. On examination, his blood pressure is 98/55 mm Hg, heart rate is 118 beats per minute, respiratory rate is 32 breaths per minute, oxygen saturation is 94% on a nonrebreather, and temperature is 36.0 degrees C (96.8 degrees F). His Glasgow Coma Scale score is 12 (eyes 3, verbal 4, motor 5). Given the unclear events surrounding his presentation and the concern for trauma, the patient is boarded and collared. His chest is stable but tender, and because of noise in the resuscitation room, you have difficulty auscultating breath sounds. The abdominal examination is notable for marked tenderness over the right upper quadrant and right flank, with some guarding. There is also mild asymmetric swelling of his right lower extremity. The patient is critically ill, his history is limited, and at this point the differential is quite broad. You consider the possibility of a syncopal episode followed by a fall, with a closed head injury, blunt thoracic trauma, and blunt abdominal trauma. His hypotension could be secondary to hypovolemia (dehydration or blood loss due to a ruptured aortic aneurysm), heart failure (left- or right-sided dysfunction), cardiac tamponade, tension pneumothorax, or sepsis. Your ED recently purchased an ultrasound machine, you wonder whether bedside ultrasound can help narrow the differential and guide your resuscitation. You call over one of your new faculty members who just finished resident training; a fortunate decision for both you and the patient.

[Successful repair of right atrial rupture due to nonpenetrating trauma of the chest].

A 24-year-old male was brought to our hospital after being injured in a traffic accident. On arrival, his blood pressure was 70/44 mmHg and his pulse rate was 135/min and regular. Chest X-p revealed cardiomegaly but there was no pleural effusion or bone fracture. Echocardiogram revealed cardiac tamponade and he was diagnosed as cardiac rupture due to non penetrating trauma. Under midline sternotomy, right atrial rupture was repaired. The patient developed cardiac arrest lasting approximately 8 minutes during anesthetic induction, so he needed to be ventilated for 8 days. However his postoperative course was not so eventful and he was discharged 38 days after surgery without any neurophysiological disturbance.

Chest injury

Classification Chest injuries can be classified as blunt or penetrating. Blunt and penetrating injuries have different pathophysiologies and clinical courses. Specific types of injuries include: Injuries to the chest wall Chest wall contusions or hematomas. Rib fractures Flail chest Sternal fractures Fractures of the shoulder girdle Pulmonary injury (injury to the lung) and injuries involving the pleural space Pulmonary contusion Pulmonary laceration Pneumothorax Hemothorax Hemopneumothorax Injury to the airways Tracheobronchial tear Cardiac injury Pericardial tamponade Myocardial contusion Traumatic arrest Hemopericardium Blood vessel injuries Traumatic aortic rupture Thoracic aorta injury Aortic dissection And injuries to other structures within the torso Esophageal injury (Boerhaave syndrome) Diaphragm injury

Outcome of Patients Underwent Emergency Department Thoracotomy and Its Predictive Factors.

Emergency department thoracotomy (EDT) may serve as the last survival chance for patients who arrive at hospital in extremis. It is considered as an effective tool for improvement of traumatic patients' outcome. The present study was done with the goal of assessing the outcome of patients who underwent EDT and its predictive factors. In the present study, medical charts of 50 retrospective and 8 prospective cases underwent emergency department thoracotomy (EDT) were reviewed during November 2011 to June 2013. Comparisons between survived and died patients were performed by Mann-Whitney U test and the predictive factors of EDT outcome were measured using multivariate logistic regression analysis. P < 0.05 considered statistically significant. Fifty-eight cases of EDT were enrolled (86.2% male). The mean age of patients was 43.27±19.85 years with the range of 18-85. The mean time duration of CPR was recorded as 37.12±12.49 minutes. Eleven cases (19%) were alive to be transported to OR (defined as ED survived). The mean time of survival in ED survived patients was 223.5±450.8 hours. More than 24 hours survival rate (late survived) was 6.9% (4 cases). Only one case (1.7%) survived to discharge from hospital (mortality rate=98.3%). There were only a significant relation between ED survival and SBP, GCS, CPR duration, and chest trauma (p=0.04). The results demonstrated that initial SBP lower than 80 mmHg (OR=1.03, 95% CI: 1.001-1.05, p=0.04) and presence of chest trauma (OR=2.6, 95% CI: 1.75-3.16, p=0.02) were independent predictive factors of EDT mortality. The findings of the present study showed that the survival rate of trauma patients underwent EDT was 1.7%. In addition, it was defined that falling systolic blood pressure below 80 mmHg and blunt trauma of chest are independent factors that along with poor outcome.

List of medical mnemonics

Imobilisation/surgery in the last 4 weeks (1.5) Previous DVT/PE Blood in sputum (haemoptysis) (1) Active cancer (1) Two tier score: PE likely > 4 Causes of life-threatening chest pain PET-MAC P = Pulmonary embolism E = Esophageal rupture T = Tension pneumothorax M = Myocardial infarction A = Aortic dissection C = Cardiac tamponade GCS intubation Under 8, intubate. Ipecac: contraindications 4 C's: Comatose Convulsing Corrosive hydrocarbon JVP: raised JVP differential PQRST(EKG waves): Pericardial effusion Quantity of fluid raised (fluid over load) Right heart failure Superior vena caval obstruction Tricuspid stenosis/tricuspid regurgitation/tamponade (cardiac) MI: immediate treatment DOGASH: Diamorphine Oxygen GTN spray Aspirin 300 mg Streptokinase Heparin PEA/asystole (ACLS): cause ITCHPAD Infarction Tension pneumothorax Cardiac tamponade Hypovolemia/hypothermia/hypo-,hyperkalemia/hypomagnesmia/hypoxemia Pulmonary embolism Acidosis

Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma.

Blunt chest trauma resulting in massive hemothorax requires immediate attention. We investigated the diagnostic and prognostic utility of various clinical factors in patients with deep pulmonary laceration caused by blunt chest trauma with a view toward interventional treatment. We reviewed 42 patients with deep pulmonary laceration resulting from blunt chest trauma who were treated between 1988 and 2008. Various clinical factors were compared between survivors and nonsurvivors. Of the 42 patients, 29 (69%) survived. Median (25th, 75th percentile) systolic blood pressure at arrival was 102 (76, 121) mm Hg for survivors and 70 (60, 90) mm Hg for nonsurvivors (p = 0.015). The median heart rate at arrival was 107 (98, 120) beats/min for survivors and 130 (120, 140) beats/min for nonsurvivors (p = 0.014). Respiratory rate, Glasgow Coma Scale score, and arterial blood gas values did not affect prognosis. Blood loss through the chest tube at insertion was 500 (400, 700) mL for survivors and 700 (500, 1000) mL for nonsurvivors (p = 0.147) and within 2 hours of arrival was 850 (590, 1100) mm Hg and 1600 (1400, 2000) mL, respectively (p < 0.001). Blood loss during thoracotomy was 1170 (600, 1790) mL and 3500 (2000, 6690), respectively (p < 0.001). In patients with deep pulmonary laceration, hemorrhagic shock with systolic blood pressure less than 80 mm Hg and heart rate more than 120 beats/min leads to a poor prognosis. Emergency thoracotomy and pulmonary lobectomy should be performed before the intrathoracic hemorrhage reaches 1200 mL.

Gunshot wound

Chest Important anatomy in the chest includes the chest wall, ribs, spine, spinal cord, intercostal neurovascular bundles, lungs, bronchi, heart, aorta, major vessels, esophagus, thoracic duct, and diaphragm. Gunshots to the chest can thus cause severe bleeding (hemothorax), respiratory compromise (pneumothorax, hemothorax, pulmonary contusion, tracheobronchial injury), cardiac injury (pericardial tamponade), esophageal injury, and nervous system injury.

Thoracoscopic diagnosis of traumatic pericardial rupture with cardiac hernia: A case report.

Pericardial rupture caused by blunt chest trauma is rare in clinical practice. Because of its atypical clinical symptoms, and because surgeons are often unfamiliar with the clinical and radiological manifestations of the injury, preoperative diagnosis is difficult; it is easily misdiagnosed and causes serious consequences. A 60-year-old man, previously healthy, was transported to the emergency room after falling from a great height. Upon arrival, his vital signs were stable. Electrocardiography and echocardiography were performed, and there was no sign of cardiac injury or ischemia. Chest and abdomen computerized tomography revealed pneumopericardium, hemopneumothorax, lung contusion, multiple rib fractures on the right side (Figure 1), and right scapula and clavicle fractures. He was admitted to the inpatient department for further observation after tube thoracostomy. The next day, the patient suddenly experienced rapid arrhythmia (the ventricular rate reached 150-180 beats/min) when turning onto his right side, accompanied by a blood pressure drop to 70/45 mm Hg and a chief complaint of palpitation. Thoracoscopy was performed urgently, and a large vertical tear (8 cm × 6 cm) was found in the pericardium. The defect was successfully repaired using a heart Dacron patch. His postoperative condition was uneventful without any fluctuations in vital signs, and he was transferred to the orthopedics department for further surgery on postoperative day 8. Although the possibility of pericardial rupture combined with cardiac hernia is extremely low, it is one of the causes of cardiogenic shock following blunt trauma. Therefore, clinicians need to be more familiar with its characteristic manifestations and maintain a high degree of vigilance against such injuries to avoid disastrous consequences.

[Traumatic Right Atrial Rupture with Left Hemothorax but without Hemopericardium:Report of a Case].

Traumatic cardiac rupture is mostly accompanied by tamponade and/or hemopericardium. We experienced a rare case of traumatic right atrial rupture with left hemothorax, but without hemopericardium. A 36-year-old male had a traffic accident, and was transported to our hospital. He was in a state of shock caused by massive hemothorax. He underwent emergency operation through median sternotomy. No blood was seen in the pericardium nor injury of any major vessels or lungs. When the heart was exposed, massive bleeding occurred. A tear of 30 mm in length was found in the right atrium at the junction of the superior vena cava. The tear was repaired under cardiopulumonary bypass. Even after surgery, however, he remained unconscious.

Simple pneumopericardium due to blunt trauma progressing to tension pneumopericardium during transportation.

Patients with simple pneumopericardium due to blunt thoracic trauma occasionally progressed to tension pneumopericardium, although pneumopericardium is believed to be benign in general. A 65-year-old man had both arms caught in a grinding machine and his face struck hard at work. He was diagnosed with bilateral degloving injuries of both arms and mediastinal emphysema on computed tomography. He required transfer to an advanced emergency medical service center for treatment. Although he was hemodynamically stable then, the patient's condition deteriorated during transportation. The patient returned to the local hospital as cardiopulmonary resuscitation continued, repeat computed tomography was performed, which showed a substantial pneumopericardium and exacerbation of mediastinal and subcutaneous emphysema. After then, cardiopulmonary resuscitation was discontinued because there was no response. For the patient to be rescued in this situation, thoracotomy is required, although it should be reserved for patients with evidence of hemodynamic compromise attributable to cardiac tamponade.

Cardiac tamponade

Differential diagnosis Initial diagnosis of cardiac tamponade can be challenging, as there is a broad differential diagnosis. The differential includes possible diagnoses based on symptoms, time course, mechanism of injury, patient history. Rapid onset cardiac tamponade may also appear similar to pleural effusions, shock, pulmonary embolism, and tension pneumothorax. If symptoms appeared more gradually, the differential diagnosis includes acute heart failure. In a person with trauma presenting with pulseless electrical activity in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is cardiac tamponade.

Thoracic Trauma -- History and Physical

The initial evaluation of a trauma patient is based on the ATLS protocol. This begins with an assessment of the patient's airway, breathing, and circulation (ABCs) during the primary survey, typically in that order. The initial evaluation of the patient who has sustained blunt or penetrating thoracic trauma is similar and geared toward the rapid identification of immediately life-threatening conditions, namely tension pneumothorax, cardiac tamponade, aortic injury, massive hemothorax, and tracheobronchial disruption. The clinician must pay careful attention to the patient's appearance on arrival to the trauma bay. Signs of respiratory distress, agitation, diaphoresis, or unwillingness to lay flat suggest underlying cardiopulmonary injuries, such as tension pneumothorax or cardiac tamponade, in which case the breathing or circulation portions of the primary survey would need to be addressed and intervened upon first, as indicated. Intubating such patients may exacerbate the pneumothorax or hypotension and lead to cardiovascular collapse due to the increased intrathoracic pressure generated by positive pressure ventilation. Therefore, if time and personnel allow, these interventions should be performed while the patient is prepared for intubation. However, assessment of the airway is generally performed first to establish patency and evaluate the need for intubation. The assessment of breathing begins at the trachea, which is inspected and palpated to ensure that it is midline and not deviated. The chest wall in then inspected for asymmetry, auscultated for breath sounds, and palpated for tenderness, crepitus, and to detect flail segments. In assessing circulation, hypotension in the setting of thoracic trauma should raise suspicion for tension pneumothorax or tamponade, which need urgent intervention before further evaluation of the patient can proceed.

Penetrating trauma

Chest Most penetrating injuries are chest wounds and have a mortality rate (death rate) of under 10%. Penetrating chest trauma can injure vital organs such as the heart and lungs and can interfere with breathing and circulation. Lung injuries that can be caused by penetrating trauma include pulmonary laceration (a cut or tear) pulmonary contusion (a bruise), hemothorax (an accumulation of blood in the chest cavity outside of the lung), pneumothorax (an accumulation of air in the chest cavity) and hemopneumothorax (accumulation of both blood and air). Sucking chest wounds and tension pneumothorax may result.

A case of traumatic cardiac tamponade showing sudden spontaneous disappearance of the pericardial fluid.

Traumatic cardiac tamponade must be treated by pericardial drainage as soon as possible. We recently encountered a rare case of traumatic cardiac tamponade in which the pericardial fluid disappeared spontaneously immediately before the planned drainage. This case is reported in this paper. The patient was a 22-year-old male who was transported to our hospital after he sustained injuries in a traffic accident. The patient was diagnosed to have a facial bone fracture, bilateral lung contusions, myocardial contusion (suspected), injury to the spinal cord at the L3-L4 level, injury to the left kidney and pelvic fracture. After TAE was performed to deal with the bleeding from the injured pelvis, the patient was immediately hospitalized. About 6 hours after the injury, pericardial fluid accumulation began to be noted, and about 18 hours after the injury, the patient went into shock, responding poorly to fluid resuscitation and treatment with pressor agents. At this time, a diagnosis of cardiac tamponade was made and emergency operation was arranged for. However, just before this could be executed, the patient's blood pressure showed a sharp rise, accompanied by disappearance of the pericardial fluid. He continued to show steady improvement and could eventually be discharged from the hospital.

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma.

We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings were recorded in a standardized fashion by the ED faculty physician. Thoracic injuries included the following: pulmonary contusion, hemothorax, pneumothorax, pneumomediastinum, tracheal-bronchial disruption, aortic injury, hemopericardium, pneumopericardium, cardiac contusion, rib fracture, sternal fracture, or any injury to the diaphragm. Multiple logistic regression and recursive partitioning analyses were performed to generate a clinical prediction rule for identifying children with these injuries. Nine hundred eighty-six patients with a mean age of 8.3+/-4.8 years were enrolled. Eighty (8.1%; 95% confidence interval [CI] 6.5% to 10.0%) patients sustained thoracic injuries. Multiple logistic regression and recursive partitioning analyses identified the following predictors of thoracic injuries: low systolic blood pressure (14% with injury versus 2% without injury; adjusted odds ratio [OR] 4.6), elevated age-adjusted respiratory rate (51% versus 16%; adjusted OR 2.9), abnormal results on examination of the thorax (68% versus 36%; adjusted OR 3.6), abnormal chest auscultation findings (14% versus 1%; adjusted OR 8.6), femur fracture (13% versus 5%; adjusted OR 2.2), and a Glasgow Coma Scale (GCS) score of less than 15 (61% versus 26%; adjusted OR 3.3). Seventy-eight (98%; 95% CI 91% to 100%) of the 80 patients with thoracic injuries had at least 1 of these predictive factors. Three hundred thirty-six (37%) children had none of these predictive factors, including 2 (0.6%; 95% CI 0.1% to 2.1%) with thoracic injuries. These 2 injuries, however, did not require any intervention. Predictors of thoracic injury in children sustaining blunt torso trauma include low systolic blood pressure, elevated respiratory rate, abnormal results on thoracic examination, abnormal chest auscultation findings, femur fracture, and a GCS score of less than 15. These predictors can be used to create a sensible clinical decision rule for the identification of children with thoracic injuries.


They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus (5).

They are undoubtedly describing the typical lesions (both on skin and oral mucosa) of a lichen planus ([HIDDEN]).

Patient presenting since 2 weeks ago with a pruritic eruption consisting of multiple polygonal erythematous-violaceous papules, flattened surface, preferentially located on the anterior aspect of wrists, pretibial area and lumbar area. She also presents whitish reticulated lesions in the jugal mucosa. What is the most probable diagnosis?

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

Segmental lesions in pityriasis rosea: a rare presentation.

A 34-year-old nonpregnant woman noted a mildly pruritic skin lesion on her right breast for 1 week following an episode of coryza, malaise, and low-grade fever of 3 days' duration. The latter symptoms subsided without any treatment. Ketoconazole cream prescribed by her family physician did not resolve the breast eruption after 1 week, so was stopped. A week later, multiple skin lesions erupted suddenly on her right chest wall starting near the herald patch in midaxillary line and spread distally until the midback. She then consulted the authors. She denied a history of abrasion or trauma to the affected areas. Travel, contact, sexual, and drug histories were unremarkable. She categorically denied past or family history of eczema, psoriasis, contact dermatitis, and drug eruptions. On examination, the initial lesion was an annular and well-demarcated erythematous plaque on her right breast in the upper outer quadrant. Multiple small oval scaly plaques were noted, extending distally along the ribs to the midline on her back, not crossing the midline, predominantly over the distribution of right T4 dermatome (Figure 1). Peripheral collarette scaling was noted (Figure 2). A few scattered small lesions were also noted in the vicinity of this dermatome. Three isolated small plaques were also present on the trunk, one in the supramammary area and the other two on the abdomen and back, respectively. Palmoplantar and mucosal surfaces were uninvolved. The rest of the skin and systemic examination revealed no abnormalities. Complete blood cell counts, fasting glucose, and urinalysis were normal. Venereal Disease Research Laboratory (VDRL) results were nonreactive and human immunodeficiency virus (HIV) antibodies were negative. Repeat testing ofVDRL in serial dilutions and HIV antibodies after 3 months were also nonreactive and negative, respectively. Scrapings from the initial large lesion and subsequent smaller eruptions did not show any evidence of fungal infection on potassium hydroxide smear examination. The patient declined skin biopsy; however, we thought that the most diagnostic label for this condition was pityriasis rosea. Hence, we treated her with triamcinolone acetonide ointment 0.025% to be applied twice daily and desloratadine tablet 5 mg daily for 10 days. The patient demonstrated complete resolution, leaving postinflammatory hypopigmentation. There was no recurrence until 1 year after complete remission.

[Follicular psoriasis with cicatricial alopecia. Piccardi-Lassueur-Graham Little syndrome of a psoriatic nature].

The case of a 21 years old female patient is reported who has had scaly lesions on the scalp since the age of 3, alopecia (later scarring alopecia) since the age of 5, and erythematous and squamous lesions on the trunk and limbs since the age of 14. More recently she developed grouped follicular papules on the trunk, back of the neck and upper limbs. Seven biopsies from the scalp, trunk and sole of foot were performed which showed typical psoriatic changes in all but one, from the scalp, where only scarring alopecia changes could be found. In one lesion from the trunk pseudogranulomatous features were observed in some papillae which were probably due to ectasia, tortuosity and endothelial proliferation of papillary blood vessels. The oral administration of RO 10-9359 was followed by a good remission of the lesions with exception of the scalp alopecia. The differential diagnosis, particularly with pityriasis rubra pilaris and lichen planus, is discussed and the similarities of our case with the Piccardi-Lassueur-Graham Little syndrome emphasised. If one accepts multiple diseases as the cause of the syndrome psoriasis could be admitted as one of them.

Hyperkeratotic Palmoplantar Lichen Planus in a child.

Lichen planus (LP) is a common idiopathic inflammatory disorder that affects the flexor aspect of the wrists, the legs, and the oral and genital mucosa. Depending upon the site of involvement, LP can be divided into mucosal, nail, scalp, or palmoplantar types. Palmoplantar LP can pose a diagnostic problem to the clinician as it resembles common dermatoses like psoriasis, verruca, corn, calluses, lichenoid drug eruption, and papular syphilide of secondary syphilis. In this case report, we describe a 4-year-old male child who presented with highly pruritic erythematous to violaceous hyperkeratotic papules and plaques on his palms and soles. Typical LP papules were noted on the upper back. Histopathology of the papular lesion showed features of LP. Dermatoscopy of a papule from the back showed the characteristic Wickham striae. We report this rare involvement of palm and soles in a case of childhood LP.

Annular Lesions: Diagnosis and Treatment.

Annular lesions can present in a variety of diseases. Knowledge of the physical appearance and history of presentation of these skin findings can help in the diagnosis. A pruritic, annular, erythematous patch that grows centrifugally should prompt evaluation for tinea corporis. Tinea corporis may be diagnosed through potassium hydroxide examination of scrapings. Recognizing erythema migrans is important in making the diagnosis of Lyme disease so that antibiotics can be initiated promptly. Plaque psoriasis generally presents with sharply demarcated, erythematous silver plaques. Erythema multiforme, which is due to a hypersensitivity reaction, presents with annular, raised lesions with central clearing. Lichen planus characteristically appears as planar, purple, polygonal, pruritic papules and plaques. Nummular eczema presents as a rash composed of coin-shaped papulovesicular erythematous lesions. Treatment is aimed at reducing skin dryness. Pityriasis rosea presents with multiple erythematous lesions with raised, scaly borders, and is generally self-limited. Urticaria results from the release of histamines and appears as well-circumscribed, erythematous lesions with raised borders and blanched centers. Annular lesions occur less commonly in persons with fixed drug eruptions, leprosy, immunoglobulin A vasculitis, secondary syphilis, sarcoidosis, subacute cutaneous lupus erythematosus, and granuloma annulare.

Dermoscopy of Gottron's papules and other inflammatory dermatoses involving the dorsa of the hands.

Several inflammatory dermatoses, including dermatomyositis (DM), may present as erythematous papules or plaques on the dorsal aspects of the hands over the joints. Limited skin involvement in these entities may pose a diagnostic challenge. (Video)dermoscopy is being utilized more frequently to aid in the differential diagnosis of inflammatory skin conditions. To describe the dermoscopic findings in Gottron's papules and compare them with dermoscopic features of other dermatoses involving the dorsal aspects of the hands. Videodermoscopic images from patients presenting with erythematous papules or plaques on the dorsal surface of the hands were retrospectively analysed for the presence of standardized dermoscopic parameters. Dermoscopic images from patients with DM (n = 12), psoriasis (n = 19), chronic dermatitis (n = 16), mycosis fungoides (n = 7), lichen planus (n = 5) and pityriasis rubra pilaris (n = 3) were included. Gottron's papules were characterized by pleomorphic vessels (dotted vessels accompanied by thick or thin linear vessels with branches or linear curved vessels) in 66.7% of cases, arranged in an unspecified pattern (91.7%), and accompanied by white or pink structureless areas (75.0%). Psoriatic plaques were characterized by dotted vessels arranged in a uniform pattern (94.7%). Vessels arranged in a ring pattern were nearly exclusively observed in psoriasis, while yellow structureless areas and erosions were more frequently present in chronic dermatitis. White lines, corresponding to Wickham striae, were specific for lichen planus. Videodermoscopy might be of value in differentiating Gottron's papules from other dermatoses involving dorsa of the hands.

Dermoscopy in differential diagnosis of inflammatory dermatoses and mycosis fungoides.

The use of dermoscopy for the evaluation of various inflammatory dermatoses has witnessed a gradual increase in recent years. The present study describes and highlights the importance of dermoscopic findings in the differential diagnosis of plaque psoriasis (PP), lichen planus (LP), mycosis fungoides (MF), pityriasis rosea (PR), and nummular dermatitis (ND) that mostly involve the trunk. The study included 150 cases (PP:50, LP:30, MF:20, PR:30, ND:20). The lesions were inspected using a polarized dermoscope. The dermoscopic findings of each lesion were evaluated for background color, type, and distribution of vessels, color and distribution of scales, and other additional findings. When the patient groups were evaluated for background color, yellow color was prominent in PR, and light and dull red color was prominent in other groups. Dotted vessels were prominent in PP, PR, and ND, and dotted + linear vessels were significantly more prominent in MF and LP. In the evaluation of the distribution pattern of vessels, PP showed regular, LP showed peripheral, and PR, MF, and ND showed patchy distribution patterns. White scales were prominent in PP, PR, and MF, and yellow-white scales were prominent in LP and ND. Only PR had a predominant peripheral distribution of scales, while other groups had a patchy distribution. In conclusion, it was observed that PP, LP, MF, PR, and ND exhibited specific dermoscopic patterns that might be useful in clinical diagnosis.

The practical usefulness of dermoscopy in general dermatology.

Beside to traditional use, dermoscopy is more and more used in the assessment of other "general" dermatologic conditions, namely scalp and hair disorders (trichoscopy), nails abnormalities (onychoscopy), skin infections and infestations (entomodermoscopy), and cutaneous inflammatory diseases (inflammoscopy). Among the list of new applications of dermoscopy, the study of inflammatory dermatoses is probably the most promising topic in terms of development and usefulness, considering the large number of such disorders and the frequent problems in their differential diagnosis which the dermatologist encounters in own daily clinical practice. In this paper, we report selected relatively common clinical differential diagnosis issues concerning inflammatory dermatoses (and some clinically related noninflammatory conditions), analysing them by a dermoscopic point of view in order to assist their noninvasive resolution according to the available literature data and our personal experience, including papulosquamous dermatoses (guttate psoriasis, pityriasis lichenoides chronica, pityriasis rosea, lichen planus, lymphomatoid papulosis, classic pityriasis rubra pilaris, papulosquamous sarcoidosis, disseminated forms of porokeratosis and papulosquamous chronic GVHD), dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides, subacute cutaneous lupus erythematosus), palmar psoriasis vs. chronic hand eczema, scalp psoriasis vs. seborrheic dermatitis, erythematous-desquamative disorders typically involving the elbows (psoriasis vulgaris, circumscribed juvenile pityriasis rubra pilaris, dermatomyositis/Gottron's sign), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), common facial inflammatory skin diseases (rosacea, seborrheic dermatitis and demodicidosis), lichen sclerosus vs. morphea, urticaria vs. urticarial vasculitis and common inflammatory cicatricial alopecia (discoid lupus erythematosus, lichen planopilaris and folliculitis decalvans).

Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea.

Dermoscopy is useful in evaluating skin tumours, but its applicability extends also to the field of inflammatory skin disorders. Plaque psoriasis (PP), dermatitis, lichen planus (LP) and pityriasis rosea (PR) are common inflammatory skin diseases, but little is currently known about their dermoscopic features. To determine and compare the dermoscopic patterns associated with PP, dermatitis, LP and PR and to assess the validity of certain dermoscopic criteria in the diagnosis of PP. Patients with PP, dermatitis, LP and PR were prospectively enrolled. The single most recently developed lesion was examined dermoscopically and histopathologically. Variables included vascular morphology, vascular arrangement, background colour, scale colour, scale distribution and presence of Wickham striae. Univariate and adjusted odds ratios were calculated. Discriminant functions were used to plot receiver-operator characteristic curves. Eighty-three patients with PP and 86 patients with either dermatitis, LP or PR were included in the study. Dotted vessels in a regular arrangement over a light red background and white scales were highly predictive for the diagnosis of PP, whereas dermatitis more commonly showed yellow scales and dotted vessels in a patchy arrangement. PR was characterized by yellowish background, dotted vessels and peripheral scales; whitish lines (Wickham striae) were seen exclusively in LP. PP, LP, PR and dermatitis show specific dermoscopic patterns that may aid their clinical diagnosis. Certain combinations of dermoscopic features can reliably predict the diagnosis of PP.

Lichen Planus -- History and Physical

Lichen planus can display a variety of lesion types, but the most common presentation is an area of polygon-shaped, itchy, violaceous, flat-topped papules a few millimeters wide. This classic presentation is known as The Six Ps of LP: purple, polygonal, planar, pruritic papules, and plaques. The lesions have a shiny surface covered in fine white lines known as Wickham striae and are firm on palpation. They may be seen as a few individual lesions, found scattered widely, grouped in plaques, or arranged in annular, linear, or actinic (sun-exposed) patterns. The isomorphic response (i.e., Koebner phenomenon) can be seen in LP wherein new lesions arise in lines where scratching occurs, just as is seen in psoriasis. The most common areas of involvement include the flexor wrists, dorsal hands, lower back, ankles, and shins. Frequently a grayish-brown hyperpigmentation can be found after lesions resolve due to deposition of melanin in the superficial dermis. [5] [10]

Hypertrophic Lichen Planus Mimicking Verrucous Lupus Erythematosus.

Lichen planus is an inflammatory skin condition that can affect the hair, mucous membranes, nails, and skin. Cutaneous lichen planus typically presents as papules that are planar, polygonal, pruritic, and purple. Subtypes of lichen planus include actinic, annular, atrophic, eruptive, follicular, hypertrophic, inverse, linear, palmoplantar, pemphigoides, pigmentosus, ulcerative, vesiculobullous, and vulvovaginal. The various clinical presentations of lichen planus can mimic other dermatologic conditions. A 63-year-old woman, who presented with pruritic, hyperkeratotic plaques on the lower legs of two years duration, is described; her lesions were morphologically suggestive of verrucous lupus erythematosus. However, an examination also revealed purple papules on the wrists and white, reticulated patches on the bilateral buccal mucosa. Biopsies demonstrated lichenoid dermatitis while laboratory studies for systemic lupus erythematosus were negative. A correlation of the clinical presentation, pathology, and laboratory studies established a diagnosis of hypertrophic lichen planus. The clinical mimickers of hypertrophic lichen planus are reviewed and the therapeutic treatments for this condition discussed.

Clinicopathological Study of Non-Infectious Erythaematous Papulosquamous Skin Diseases.

Papulosquamous diseases are characterized by scaly papules and plaques with similar clinical picture which amounts to confusion and hence, a definitive histopathological diagnosis goes a long way in treatment of such diseases. The aim of the study was to study the histomorphology of non-infectious, erythaematous, papulosquamous lesions of skin with clinicopathological correlation. Skin biopsies from 150 clinically diagnosed/suspected non-infectious erythaematous, papulosquamous skin diseases were received in the Department of Pathology. The specimens obtained were subjected to formalin fixation and paraffin embedding, stained with haematoxylin and eosin and studied. The lesions were classified as psoriasis, lichen planus, lichen nitidus, lichen striatus, pityriasis rosea and pityriasis rubra pilaris and clinicopathological correlation was done. Papulosquamous lesions were common in the elderly. Males were commonly affected except in pityriasis rosea. Among the 150 cases studied, 72 cases (48%) were histopathologically confirmed to be papulosquamous lesions. Psoriasis was the most common lesion. Key histopathological features and clinicopathological correlation gives a conclusive diagnosis. The importance of specific histomorphological diagnosis lies in distinguishing these lesions as the treatment and prognosis varies widely.

Profile of lichen planus in Bangladesh.

Lichen planus is one of the common inflammatory disorders of skin, mucous membrane, nail and hair characterized by violaceous, polish, pruritic, polygonal, flat-topped papules usually distributed bilaterally symmetrically over the extremities. Our objectives in this study were to explore the prevalence of lichen planus in large area of Dhaka in Bangladesh and to establish the clinical characteristics of lichen planus. This descriptive type of cross sectional study was carried out from September 2006 to August 2008 in the Department of Dermatology and Venereology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College Hospital (DMCH) and Combined Military Hospital (CMH) in Dhaka. Patients suffering from lichen planus were selected as study population. By face to face interview and clinical observations, data were collected from sample. A total 120 patients of lichen planus were selected, on the basis of age, 30(25%) were 10-30 years of age, 75(62.56%) were 30-50 years and 16(13.33%) were over 50 years of age. The mean age of the patient was 40+/-4 years. Out of 120 patients, 80(66.66%) were male and 60(33.33%) were female and eight patients (6.67%) had positive family history among highest age group (30 to 50 years). In case of duration of disease, highest percentage (68%) of cases was 15 days to 6 months and considering clinical sign, koebnerization was present 45(37.5%) cases and Wickhams striae 22(18.33%) cases. Regarding site of onset of lesion, lesions were highest 100(83.33%) in upper limbs, next lower limbs, trunk, oral mucosa etc. The distribution of clinical pattern of lichen planus showing classic pattern (68.33%) was the most common type, followed by hypertrophic, actinic, ashy dermatoses, lichen plano-pilaris, erosive or ulcerative etc. This clinico-epidemiological study of lichen planus attending in the different hospital in Dhaka, Bangladesh has shown that lichen planus is usually associated with 30 to 50 years of age group, with higher male prevalence than female, 15 days to 6 months are mainly duration of disease, koebnerization and Wickhams striae are common clinical signs, upper limbs is mainly the site of onset of lesion, and classic pattern is the most common clinical type in lichen planus.

Pityriasis rosea

Diagnosis Experienced practitioners may make the diagnosis clinically. Classical symptoms are usually straightforward to recognize, but the wide range of atypical forms may cause difficulty for the clinician in diagnosing some cases. Misdiagnosis by nondermatologists is not uncommon. If the diagnosis is in doubt, tests may be performed to rule out similar conditions such as Lyme disease, ringworm, guttate psoriasis, nummular or discoid eczema, drug eruptions, other viral exanthems. The clinical appearance of pityriasis rosea in some cases is similar to that of secondary syphilis, and rapid plasma reagin testing should be performed if there is any clinical concern for syphilis. A biopsy of the lesions will show extravasated erythrocytes within dermal papillae and dyskeratotic cells within the dermis. A set of validated diagnostic criteria for pityriasis rosea is as follows: A patient is diagnosed as having pityriasis rosea if:

Seborrheic Dermatitis -- Differential Diagnosis -- Trunk

Psoriasis - sharply-defined red plaques with a loose, silvery lamella scale Pityriasis rosea - herald spot; collarette scale; Christmas tree distribution Pityriasis versicolor - not symmetrical; hypo/hyperpigmentation Subacute lupus erythematosus - photosensitive distribution Eczema (nummular) - intense pruritus Tinea corporis - raised leading edges and central clearing; uncommon in infants Erythema annulare centrifugum - recurrent polycyclic lesions that slowly expand and disappear Darier disease - Greasy wart-like papules and plaques Grover disease (transient acantholytic dermatosis) - acanthosis Drug reaction - drug history (neuroleptic; immunosuppressant; PUVA; lithium) Parapsoriasis - elderly; very slow growing; resistant to treatment Pemphigus foliaceus - fragile, painful blisters - Nikolsky sign is positive Secondary syphilis - lesions on the palms and soles; a history of chancre

Histopathologic diagnosis of dermatitis

Interface dermatitis with lichenoid inflammation Interface dermatitis with lichenoid inflammation, not otherwise specified, can be caused by lichen planus-like keratosis, lichenoid actinic keratosis, lichenoid lupus erythematosus, lichenoid GVHD (chronic GVHD), pigmented purpuric dermatosis, pityriasis rosea, and pityriasis lichenoides chronica. Unusual conditions that can be associated with a lichenoid inflammatory cell infiltrate are HIV dermatitis, syphilis, mycosis fungoides, urticaria pigmentosa, and post-inflammatory hyperpigmentation. In cases of post-inflammatory hyperpigmentation, it is important to exclude potentially harmful mimics such as a regressed melanocytic lesion or lichenoid pigmented actinic keratosis. Psoriaform dermatitis Examining multiple deeper levels is recommended if initial cuts do not correlate well with the clinical history.

Vesicular palmoplantar pityriasis rosea.

A 16-year-old young man presented with intensely itchy erythematous dermatitis on the body for 1 week and vesicular lesions on the palms and soles for 4 to 5 days. Lesions on the palms and soles were accompanied by severe burning and itching. The patient gave a history of sore throat and fever, 1 week prior to the onset of lesions. A general physical examination was normal, and cutaneous examination revealed multiple, well-defined erythematous scaly plaques with collaret scaling on the trunk and extremities (Figure 1). Vesicular lesions were seen on the palms and soles (Figure 2). The differential diagnoses we considered were pityriasis rosea and secondary syphilis. The possibility of dermatophytid, vesicular pityriasis rosea, and pompholyx was limited to the palms and sole lesions. Complete blood cell count was within normal limits. Results from antistreptolysin O titer, potassium hydroxide mount, and venereal disease research laboratory were negative. Skin biopsies were taken from the back and left palm. The biopsy specimen from the back revealed focal spongiosis, lymphocyte exocytosis, vacuolar changes in the basal layer, and perivascular lymphocytic infiltrate in the dermis (Figure 3). The biopsy obtained from the vesicular lesion on the left palm revealed an intraepidermal vesicle with no evidence of acantolytic process (Figure 4). A diagnosis of pityriasis rosea was made and the patient was started on clarithromycin 500 mg once a day for 7 days, along with antihistamines and emollients. The lesions faded dramatically in a very short period, and there was significant involution of almost all of the lesions after 7 days of clarithromycin. During the 6 months of follow-up, no recurrence was observed.

Lichen Nitidus -- History and Physical

Lichen nitidus usually presents as asymptomatic, shiny, flat-topped, fleshy pink to dark brown papules. They are typically 1 to 2 mm in diameter. In patients with darker skin lesions can appear as light spots. Lesions commonly present on the neck, trunk, limbs, abdomen, and penile shaft. The involvement of mucous membranes, palms, soles, and nails are rare, but there are reports. [2] [3] [4] If lichen nitidus is symptomatic, the patient mainly complains of mild sporadic pruritus. [3] Koebner phenomenon is a hallmark of lichen nitidus, as seen in lichen planus, but is not present in all cases. [3] [4] Rarely lichen nitidus will present only on the palms and soles and will usually present with lichen nitidus lesions in other locations. [11] If lesions present in the oral mucosa, they will be flat, greyish papules. [3] [12]

Lichen planus

Signs and symptoms Although lichen planus can present with a variety of lesions, the most common presentation is as a well defined area of purple-coloured, itchy, flat-topped papules with interspersed lacy white lines (Wickham's striae). This description is known as the characteristic "6 Ps" of lichen planus: planar (flat-topped), purple, polygonal, pruritic, papules, and plaques. This rash, after regressing, is likely to leave an area of hyperpigmentation that slowly fades. That said, a variety of other lesions can also occur. Skin

Papule

Papules with scale on the palms and soles may occur in secondary syphilis, psoriasis, eczema, tinea manuum, mycosis fungoides. In lichen planus papules may be itchy, flat-topped, polygonal, purplish with white streaks, and can be solitary, or occur in clusters or in a line. See also List of cutaneous conditions References External links Dermatologic terminology

InternalMed_Harrison

CHAPTER 71 Eczema, Psoriasis, Cutaneous Infections, Acne, and Other Common Skin Disorders Psoriasis Sharply demarcated, erythematous plaques with mica-like scale; predominantly on elbows, knees, and scalp; atypical forms may localize to intertriginous areas; eruptive forms may be associated with infection Lichen planus Purple polygonal papules marked by severe pruritus; lacy white markings, especially associated with mucous membrane lesions Pityriasis rosea Rash often preceded by herald patch; oval to round plaques with trailing scale; most often affects trunk; eruption lines up in skinfolds giving a “fir tree–like” appearance; generally spares palms and soles Dermatophytosis Polymorphous appearance depending on dermatophyte, body site, and host response; sharply defined to ill-demarcated scaly plaques with or without inflammation; may be associated with hair loss May be aggravated by certain drugs, infection; severe forms seen in association with HIV

Malassezia Furfur -- Differential Diagnosis

Several dermatologic disorders may mimic PV. SD may occur on the trunk as PV does, but lesions are more erythematous with thicker scaling, and other locations, including the scalp, are usually involved. Pityriasis rosea may be differentiated from PV by the appearance of a herald patch before the onset of symptoms, "Christmas tree" distribution, and erythematous, scaling macules and patches. Whereas PV causes hypopigmented skin lesions, those seen in vitiligo are depigmented. The eczematous lesions of pityriasis alba also may appear as hypopigmented macules and patches; however, the face is primarily affected, and affected children typically have a history of atopy. Secondary syphilis must be ruled out in a patient with generalized hyperpigmented macules involving the palms and soles. Mycosis fungoides may present as hypopigmented lesions on the trunk and extremities, but scaling, erythema, and plaques are more characteristic. [17]

Papulosquamous disorder

A papulosquamous disorder is a condition which presents with both papules and scales, or both scaly papules and plaques. Examples include psoriasis, lichen planus, and pityriasis rosea. See also List of cutaneous conditions References Further reading http://www.emedicine.com/derm/index.shtml#papulosquamous External links Dermatologic terminology Papulosquamous disorders

Pityriasis amiantacea

Diagnosis Pityriasis amiantacea can easily be misdiagnosed due to its close resemblance to other scalp diseases such as psoriasis, seborrhoeic dermatitis or lichen planus. However, in pityriasis amiantacea the scales are attached to both the hair shaft and the scalp. Pityriasis amiantacea may be present with other inflammatory conditions such as atopic dermatitis or seborrhoeic dermatitis and sebaceous scales and alopecia can occur. According to Bolognia's textbook "Dermatology," this rare condition is most often combined with psoriasis, but it may also develop as secondarily infected atopic dermatitis, seborrheic dermatitis, and/or tinea capitis. Treatment

Epidermodysplasia verruciformis

Signs and symptoms Clinical diagnostic features are lifelong eruptions of pityriasis versicolor-like macules, flat wart-like papules, one to many cutaneous horn-like lesions, and development of cutaneous carcinomas. Patients present with flat, slightly scaly, red-brown macules on the face, neck, and body, recurring especially around the penial area, or verruca-like papillomatous lesions, seborrheic keratosis-like lesions, and pinkish-red plane papules on the hands, upper and lower extremities, and face. The initial form of EV presents with only flat, wart-like lesions over the body, whereas the malignant form shows a higher rate of polymorphic skin lesions and development of multiple cutaneous tumors. Generally, cutaneous lesions are spread over the body, but some cases have only a few lesions which are limited to one extremity.

Psoriasis

Diagnosis A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch. No special blood tests or diagnostic procedures are usually required to make the diagnosis. The differential diagnosis of psoriasis includes dermatological conditions similar in appearance such as discoid eczema, seborrheic eczema, pityriasis rosea (may be confused with guttate psoriasis), nail fungus (may be confused with nail psoriasis) or cutaneous T cell lymphoma (50% of individuals with this cancer are initially misdiagnosed with psoriasis). Dermatologic manifestations of systemic illnesses such as the rash of secondary syphilis may also be confused with psoriasis.

Palmar lichen planus mimicking tinea nigra.

Lichen planus (LP) is a chronic inflammatory skin disease characterized by polygonal, violaceous papules commonly involving flexural areas of the wrists, legs, and oral and genital mucous membranes. This report describes a patient who presented with asymptomatic black colored patches on both palms simulating Tinea nigra, a superficial fungal infection. She was previously diagnosed as allergic contact dermatitis and was being treated with potent topical steroid i.e. clobetasol propionate 0.05% and white soft paraffin. Dermatoscopy of the lesion showed brownish pigmentation along ridges of the dermatoglyphics. A biopsy from the lesional skin showed findings of lichen planus. Our case highlights the potential diagnostic confusion that can occur with unusual variants of palmoplantar lichen planus and importance of histopathology in diagnosis of such unusual lesions.

Lichen planus

Lichen planus (LP) is a chronic inflammatory and immune-mediated disease that affects the skin, nails, hair, and mucous membranes. It is not an actual lichen, and is only named that because it looks like one. It is characterized by polygonal, flat-topped, violaceous papules and plaques with overlying, reticulated, fine white scale (Wickham's striae), commonly affecting dorsal hands, flexural wrists and forearms, trunk, anterior lower legs and oral mucosa. Although there is a broad clinical range of LP manifestations, the skin and oral cavity remain as the major sites of involvement. The cause is unknown, but it is thought to be the result of an autoimmune process with an unknown initial trigger. There is no cure, but many different medications and procedures have been used in efforts to control the symptoms.

Pemphigoid

Presentation Primary lesions of small and large blisters, known as vesicles and bullae, are found on the skin and sometimes on the mucous membranes. Non-bullous pemphigoid In some patients, pemphigoid starts off with cutaneous manifestations of BP without bullae, as the only sign of the disease. Pruritic eczematous, papular, or urticaria-like skin lesions may also persist for weeks to months. Bullous phase The bullous stage of BP shows vesicles and bulla, appearing on apparently normal or erythematous skin, predominantly at the flexural aspects of the extremities and the lower trunk. Mucosal lesions, which typically are erosions of the oral mucosa, are present in 10 to 30 percent of patients. Occasionally, the blister fluid becomes blood-tinged. The blisters are tense, about 1–4 cm in diameter, leaving eroded and crusted areas, together with urticarial and infiltrated papules and plaques in an annular or figurate pattern.

InternalMed_Harrison

Lichen planus (LP) is a papulosquamous disorder that may affect the skin, scalp, nails, and mucous membranes. The primary cutaneous lesions are pruritic, polygonal, flat-topped, violaceous papules. Close examination of the surface of these papules often reveals a network of gray lines (Wickham’s striae). The skin lesions may occur anywhere but have a predilection for the wrists, shins, lower back, and genitalia (Fig. 71-5). Involvement of the scalp (lichen planopilaris) may lead to scarring alopecia, and nail involvement may lead to permanent deformity or loss of fingernails and toenails. LP commonly involves mucous membranes, particularly the buccal mucosa, where it can present on a spectrum ranging from a mild, white, reticulate eruption of the mucosa to a severe, erosive stomatitis. Erosive stomatitis may persist for years and may be linked to an increased risk of oral squamous cell carcinoma. Cutaneous eruptions clinically resembling LP have been observed after administration of

Dermoscopy in General Dermatology: A Practical Overview.

Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides and subacute cutaneous lupus erythematosus), papulosquamous/papulokeratotic dermatoses (lichen planus, pityriasis rosea, papulosquamous sarcoidosis, guttate psoriasis, pityriasis lichenoides chronica, classical pityriasis rubra pilaris, porokeratosis, lymphomatoid papulosis, papulosquamous chronic GVHD, parakeratosis variegata, Grover disease, Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis), facial inflammatory skin diseases (rosacea, seborrheic dermatitis, discoid lupus erythematosus, sarcoidosis, cutaneous leishmaniasis, lupus vulgaris, granuloma faciale and demodicidosis), acquired keratodermas (chronic hand eczema, palmar psoriasis, keratoderma due to mycosis fungoides, keratoderma resulting from pityriasis rubra pilaris, tinea manuum, palmar lichen planus and aquagenic palmar keratoderma), sclero-atrophic dermatoses (necrobiosis lipoidica, morphea and cutaneous lichen sclerosus), hypopigmented macular diseases (extragenital guttate lichen sclerosus, achromic pityriasis versicolor, guttate vitiligo, idiopathic guttate hypomelanosis, progressive macular hypomelanosis and postinflammatory hypopigmentations), hyperpigmented maculopapular diseases (pityriasis versicolor, lichen planus pigmentosus, Gougerot-Carteaud syndrome, Dowling-Degos disease, erythema ab igne, macular amyloidosis, lichen amyloidosus, friction melanosis, terra firma-forme dermatosis, urticaria pigmentosa and telangiectasia macularis eruptiva perstans), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), erythrodermas (due to psoriasis, atopic dermatitis, mycosis fungoides, pityriasis rubra pilaris and scabies), noninfectious balanitis (Zoon's plasma cell balanitis, psoriatic balanitis, seborrheic dermatitis and non-specific balanitis) and erythroplasia of Queyrat, inflammatory cicatricial alopecias (scalp discoid lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans), nonscarring alopecias (alopecia areata, trichotillomania, androgenetic alopecia and telogen effluvium) and scaling disorders of the scalp (tinea capitis, scalp psoriasis, seborrheic dermatitis and pityriasis amiantacea).

Genitogluteal porokeratosis: 10 years to make the diagnosis!

Genitogluteal porokeratosis, a relatively rare presentation of porokeratosis of Mibelli, often manifests in an atypical way due to its verrucous appearance that may obscure the characteristic annular keratotic rim. For this reason, misdiagnosis as other common papulosquamous diseases is not uncommon. We report a 44-year-old man with a 10-year-history of slowly progressive pruritic psoriasiform/lichenified plaques over the buttocks. Despite multiple skin biopsies, the lesions were misdiagnosed as psoriasis, lichen simplex chronicus, pityriasis rubra pilaris, and mycosis fungoides, until the last biopsy revealed findings characteristic of porokeratosis. Dermatologists and dermatopathologists should be aware of this rare and unique variant of porokeratosis, which, in addition to the atypical clinical presentation and the occasional misleading histology, may portend a better prognosis in terms of malignant degeneration.

InternalMed_Harrison

(Table 72-1) When an eruption is characterized by elevated lesions, either papules (<1 cm) or plaques (>1 cm), in association with scale, it is referred to as papulosquamous. The most common papulosquamous diseases—tinea, psoriasis, pityriasis rosea, and lichen planus—are primary cutaneous disorders (Chap. 71). When psoriatic lesions are accompanied by arthritis, the possibility of psoriatic arthritis or reactive arthritis (formerly known as Reiter’s syndrome) should be considered. A history of oral ulcers, conjunctivitis, uveitis, and/or urethritis points to the latter diagnosis. Lithium, beta blockers, HIV or streptococcal infections, and a rapid taper of systemic glucocorticoids are known to exacerbate psoriasis. Comorbidities in patients with psoriasis include cardiovascular disease and metabolic syndrome.