A member presented a medical case:
20 yr old woman with a blistering rash
A blistering, painful recurrent rash in a 20 yr old woman associated with sun exposure, unclear if this is actinic prurigo or something else.
Hispanic or Latin American
Chief complaint or problem to solve
Painful, blistering rash after sun exposure
Rash began in 2009 during summer marching band camp. Itchy bumps appeared on arms and nose was red with blisters and blackish fluid coming from it. Dermatologist treated me for impetigo (Keflex and mycolog cream), but rash did not go away. Went back and dermatologist said rash looked like a chemical burn. Tried Locoid and Mupirocin cream. Rash got worse... Blood test, lupus screen, and biopsy on arm did not reveal any definite diagnosis. Extremely painful rash with redness and yellow blisters continued to appear after sun exposure, now on my lips, nose, cheeks, and arms. Caused so much pain that I had to sleep on ice and take pain pills. Went to the ER on Nov. 2, 2009. Tests for herpes viral, bacterial, strep, and staph came back negative. Another skin biopsy taken and diagnosed with Lupus Miliaris Disseminatus Faciei. Given Prednisone, Doryx, and Aczone gel. None of these helped rash to go away. Rash continued to occur, painful and oozing. Skin resembles a burn, wiping off and wet underneath. Skin biopsy performed on cheek mid Dec. 2009. Rash has started to appear despite cloud cover outside. Porphyria test negative in March 2010 and I was advised to wear long sleeves, a hat, and avoid sun exposure. Diagnosis of exclusion in Actinic Prurigo. Abdominal pain begins in April 2010, leading to appendectomy. Rash now occurs on back as well, despite 85 spf sunscreen. Rash causes extreme fatigue. Constipation and abdominal pain occurs frequently. Went to Mayo Clinic in Florida in Sept. 2010. Bloodwork, porphyria, feces, and urine tests don't reveal anything. Diagnosis is actinic prurigo, and advised to schedule photolight treatment. Inconclusive biopsy done on neck in Oct. and feeling terrible in Dec. with terrible rash pain, nausea, and diarrhea. Doctor refuses to do photolight treatment because she is sure it isn't actinic prurigo. Rash continues to come out after being outside. Biopsy of ear, nose, and arm in May 2011 show photoallergic contact. Right breast lumpectomy in July showed benign tumor. Plaquenil in March 2012 helped rash, but it returned after stopping. Accepted to National Institute of Health Undiagnosed Diseases Program, but program lost some funding and had to drop some patients, including me. I have avoided sun exposure, but rash will come out if I get in the sun. I still have abdominal pain and am unsure if these are related.
Purpose of case discussion
Diagnostic dilemma: "What's the diagnosis?"