Browsing by Author "Weis, Stephen"
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Item CONGENITAL IDIOPATHIC HYPOGONADOTROPIC HYPOGONADISM: A CASE REPORT(2014-03) Sumko, Dan; Soutt, William; Wong, Long; Weis, StephenAbstract: Congenital idiopathic hypogonadotropic hypogonadism (IHH) is caused by the lack of production or physiological response to gonadotropin releasing hormone (GnRH). A wide variety of genetic mutations have been implicated in the disorder demonstrating autosomal dominant, recessive, and X-linked inheritance patterns. Diagnosis of IHH is complicated by its similarity in presentation to a constitutional delay of puberty and often goes undiagnosed in patients under the age of 18. Once IHH is identified, the effects of the disturbed HPA axis must be addressed. In this report, we offer a brief overview of the diagnosis and management of IHH and present the case of a 27-year old male with undiagnosed IHH. We present the following case: A 27-year old male presented to a family medicine clinic with complaint of a changing skin lesion that was a melanoma in situ. As a result he had a full-skin exam and was found to have a microphallus, undescended testes, and minimal pubic hair distribution. He had a normal sense of smell. Laboratory evaluation showed total testosterone to be 26 ng/dL (250-1100 normal), LH 0.4 mIU/mL (1.5-9.3 normal), and FSH 1.6 mIU/mL (1.6-8.0 normal). Prolactin, PTH, and calcium were within normal limits, as well as his CBC and BMP. MRI of the brain showed no lesions of the hypothalamus or pituitary gland. An abdominal CT confirmed undescended testes. DEXA scan revealed osteopenia. He was diagnosed as IHH. The patient was provided with supplementary vitamin D, calcium, and referrals to endocrinology and urology for orchiopexy. Purpose: (a): Congenital idiopathic hypogonadotropic hypogonadism (IHH) is caused by the lack of production or physiological response to gonadotropin releasing hormone (GnRH). A wide variety of genetic mutations have been implicated in the disorder demonstrating autosomal dominant, recessive, and X-linked inheritance patterns. Diagnosis of IHH is complicated by its similarity in presentation to a constitutional delay of puberty and often goes undiagnosed in patients under the age of 18. Once IHH is identified, the effects of the disturbed HPA axis must be addressed. In this report, we offer a brief overview of the diagnosis and management of IHH and present the case of a 27-year old male with undiagnosed IHH. Methods (b): A 27-year old male presented to a family medicine clinic with complaint of a changing skin lesion that was a melanoma in situ. As a result the patient had a full-skin exam and was found to have a microphallus, undescended testes, and minimal pubic hair distribution. He had a normal sense of smell. Laboratory evaluation showed total testosterone to be 26 ng/dL (250-1100 normal), LH 0.4 mIU/mL (1.5-9.3 normal), and FSH 1.6 mIU/mL (1.6-8.0 normal). Prolactin, PTH, and calcium were within normal limits, as well as his CBC and BMP. MRI of the brain showed no lesions of the hypothalamus or pituitary gland. An abdominal CT confirmed undescended testes. DEXA scan revealed osteopenia. Results (c): The patients was diagnosed as IHH. The patient was provided with supplementary vitamin D, calcium, and referrals to endocrinology and urology for orchiopexy. Conclusions (d): The diagnosis of IHH in this patient was critical for his future health. Osteoporosis, increased risk of testicular cancer secondary to cryptorchidism, and infertility are just a few of the more serious sequelae associated with IHH. When diagnosed early, these comorbidities can be reduced or even eliminated. This case highlights the value of obtaining a detailed history and performing a thorough physical examination as this patient’s risk of cancer, fractures, and infertility could have been dramatically reduced with an earlier diagnosis.Item Demonstration of Steroid Atrophy From Chronic Topical Steroid Use in Various Fitzpatrick Skin Types(2024-03-21) Martinez, Maria Francesca Ysabelle; Du, Wenqin; Wong, Christopher; Hall, Marshall; Scheufele, Christian; Weis, StephenBackground: Topical steroids are commonly prescribed first-line medications for various inflammatory and autoimmune dermatologic conditions. Their widespread use raises the importance of proper use. Topical steroids have well-known side effects including skin atrophy, redness, striae, and telangiectasias. These side effects have not been well documented in patients of various skin tones. Primary care clinicians must recognize topical steroid side effects and their appearance in various skin tones. This paper will focus on representing skin atrophy, the most common steroid side effect, in a variety of Fitzpatrick skin types. Case Presentation: We present a series of images illustrating skin atrophy after prolonged topical steroid use on various Fitzpatrick skin types. The first case shows Fitzpatrick V skin with areas of erythema, hypopigmentation, and hyperpigmentation on the trunk. The second case presents thin skin with bright erythema and purpuric papules on the upper extremities of Fitzpatrick II skin. A third case showcases symmetric, parallel, linear, maroon dermal scars perpendicular to tension lines in the background of epidermal atrophy circum-anally and on the buttocks of Fitzpatrick IV skin. A fourth case exhibits Fitzpatrick III skin with shiny, thin skin and patches of hypopigmentation and telangiectasias on bilateral cheeks. The fifth case is a Fitzpatrick IV skin type with plaque psoriasis on the lower extremity and a background of skin thinning, hypopigmentation, and visible underlying vasculature from chronic topical steroid use. The final case represents Fitzpatrick VI skin with pyoderma gangrenosum, atrophied skin with overt hypopigmented patches adjacent to a cribriform scar. These cases feature the diverse presentations of skin atrophy on different Fitzpatrick skin types. Conclusion: Steroid atrophy is the most common side effect of chronic topical steroid use. Topical steroids are widely used for dermatologic conditions such as atopic dermatitis and plaque psoriasis. Steroids work to quell these inflammatory and autoimmune conditions and are overall tolerated well with proper use. Overuse of topical steroids is common and can cause known side effects of skin atrophy, erythema, striae, and telangiectasias. Recognition of steroid overuse requires knowledge of its presentation in various skin tones. In lighter skin types, atrophy is apparent with visible underlying vasculature and bright red erythema. In darker skin types, atrophy is more subtle and underlying vasculature may appear burgundy or maroon. Awareness of these differences in presentation will allow for quick recognition and immediate cessation of steroid use to prevent further side effects.Item Favre-Racouchot Syndrome Following Image-Guided Superficial Radiation Therapy(2024-03-21) Nguyen, Cecilia; Hall, Marshall; Weis, StephenBackground: Favre-Racouchot Syndrome (FRS) is a cutaneous disease characterized by nodules, cysts, and comedones located in sun-exposed areas of the face, such as the bilateral temporal and periorbital skin. FRS is associated with chronic sun exposure, cigarette smoking, and rarely with radiation therapy. Case Information: We present the first recorded cases of Favre-Racouchot Syndrome occurring in the setting of image-guided superficial radiation therapy (IG-SRT). A 68-year-old male with a history of nodular BCC on the forehead and right arm presented for a lesion on his forehead. The patient was being treated with IG-SRT #_msocom_1to the affected areas, and he initially noticed the lesion within the radiation treatment field during the 6th week of treatment (about 75% of the way through his treatments). Also, a 59-year-old female with a history of nodular BCC on the right nasal ala, that was treated with IG-SRT, presented for a lesion on her nose. The lesion was first noted during her 2-week follow-up visit after completing her IG-SRT treatments. Both of the patients in our cases were actively smoking tobacco products throughout their radiation treatments. Our cases differ from the prior reported cases due to the form of radiotherapy being used. It is important to note that the patient in Case 1 had additional NMSCs on the forearm and trunk. The forearm BCC was treated at the same time as the forehead lesion. The trunk lesion began treatment 6 months after the forehead and forearm lesions were treated. Neither of these treatment sites developed comedones. This shows that the location of the lesion may play a role in the development of FRS, especially in those actively smoking tobacco products during treatment. Conclusion: The combination of underlying chronic actinic damage, radiation, and tobacco use may increase the risk of developing FRS. Tobacco use in conjunction with radiation treatment may have a synergistic effect. As IG-SRT is becoming increasingly more prevalent as a treatment for non-melanoma skin cancers, it is important to monitor for adverse events and complications.Item Presentations of Cutaneous Disease in Various Skin Pigmentations: Atopic Dermatitis(2023) Thompson, Jordan; Nguyen, Cecilia; Nguyen, Daniel; Wong, Christopher; Scheufele, Christian; Carletti, Michael; Weis, StephenBackground Atopic dermatitis (AD), commonly known as eczema, is a chronic inflammatory skin disorder classically affecting flexural areas of the body. It presents in any age group, but commonly develops during infancy and early childhood and morphologic subtypes exist due to varying skin tones. Children with darker skin were approximately six times more likely to develop atopic dermatitis in comparison to children with lighter skin. African American and Asian patients more frequently have atopic dermatitis compared to Caucasian patients. Presentations of atopic dermatitis vary due to duration, age and color of skin. Acute lesions are clinically characterized as ill-defined pruritic, erythematous plaques (raised, >1cm) while chronic lesions are dry, hyperpigmented plaques (raised, >1cm) with lichenification and prurigo nodules. Differential diagnosis includes scabies, seborrheic dermatitis, ichthyoses, and psoriasis. This review article will showcase clinical images with varying presentations of atopic dermatitis in ranging age groups and skin color according to the Fitzpatrick scale. Case Information The Fitzpatrick scale provides a classification system for an individual’s skin type based on the ability to burn and/or tan when exposed to ultraviolet light. It is used to approximate the degree of skin pigmentation. This review article focuses on 5 distinct cases of varying ages and skin types to present 5 atypical presentations of atopic dermatitis. Case 1 presents a 40-year-old, Fitzpatrick I, with chronic atopic dermatitis. Case 2 presents a 6-month-old, Fitzpatrick III, with acute atopic dermatitis. Case 3 presents a 11-year-old, Fitzpatrick IV, with subacute atopic dermatitis. Case 4 presents a 21-year-old, Fitzpatrick IV, with chronic atopic dermatitis. Case 5 presents a 3-year-old, Fitzpatrick V, with chronic atopic dermatitis. Discussion In the United States, atopic dermatitis affects approximately 11.3 – 12.7% and 6.9 – 7.6% of children and adults, respectively. Presentations of atopic dermatitis can vary due to duration, age and color of skin. Post inflammatory dyspigmentation is observed more in African American patients due to decreased healthcare access and different clinical manifestations, notably with erythema. Atopic dermatitis can have a significant quality of life impairment and disease burden in diagnosed individuals, especially those with darker skin pigmentation. The disease can progress to a systemic disorder, "atopic march” causing allergic conditions including asthma, allergic rhinitis and food allergies. Pruritus, a hallmark symptom of atopic dermatitis, may lead to increased sleep disturbances, fatigue, and mental health symptoms which ultimately affects growth, school performance, attention, and accident rates in children. Atopic dermatitis has been linked to attention-deficit hyperactivity disorder in children and increased rates of depression and anxiety in teengagers and adults. The purpose of this review article is to outline atypical presentations of atopic dermatitis to allow practitioners to gain a better understanding to aid in diagnosing patients with different skin tones.Item Severe Psoriatic Disease in the Setting of Hypocalcemia(2017-03-14) Reagin, Heather; Weis, Stephen; Workman, AshleighPurpose: To present a patient suffering from severe psoriatic disease in the setting of hypocalcemia and determine the best treatment. Methods: N/A Results: The patient’s psoriatic plaques cleared three months after presentation when she had achieved normocalcemia with 0.75 mcg calcitriol. Conclusions: Psoriasis is a chronic, inflammatory, systemic disease that affects approximately three percent of the US adult population. While its exact cause is uncertain, it is thought to be an autoimmune disorder. There have been very rare cases of psoriasis developing in patients with hypocalcemia. Treatment of such patients is directed at restoring the calcium to the normal range, not immunosuppressive medications.Item Sporotrichoid Lymphocutaneous Spread of Metastatic Cutaneous Squamous Cell Carcinoma(2019-03-05) Weis, Stephen; Al-Dossari, RannaBackground: Sporotrichoid lymphocutaneous spread is a dermatologic pattern characterized by superficial cutaneous lesions that follow subcutaneous lymphatics. Typically, this is observed when an infection starts at a site of distal inoculation and leads to the development of ascending nodules. The most common causes are fungal and mycobacterial infections. Metastatic cutaneous squamous cell carcinoma (CSCC) typically presents with regional lymphadenopathy. Primary lesions of the external ear and lip have the highest risk of metastasis, followed by the temple, scalp, hands, and feet. Risk factors for metastasis of CSCC include immunosuppression, tumor recurrence, tumor thickness [greater than] 4mm, and perineural or vascular invasion. However, metastasis of CSCC is rarely seen to follow a sporotrichoid lymphocutaneous morphology. Case Information: A 64-year-old female with a past medical history of severe COPD requiring repeated courses of prednisone and continuous oxygen, presented for a rapid growing lesion on her left hand after trauma in the shower at a nursing home. Due to her poor medical condition, she declined recommended biopsy with follow-up surgery. Patient underwent electrodessication and curettage surgery (EDC) followed by imiqumod treatment as she desired the least aggressive treatment. She also complained of a growth on her forearm at the initial visit. She reported after starting imiquimod, the lesion on her left hand has bled, drained and deepened in appearance. She also reported that the previous growth on her left forearm has grown in size and new lesions appeared on her upper arm and armpit. On exam, she had no healing at EDC site. She had developed an ulcer that exceeded the size of the original EDC. She had multiple erythematous, tender nodules of varying sizes on her left arm in a sporotrichoid lymphocutaneous pattern. She had left axillary lymphadenopathy. A biopsy performed of one of the nodules showed CSCC with intravascular and perineural invasion. Tissue cultures were negative for acid-fast bacilli, aerobic bacteria, mycobacteria and fungus. Chest X-ray did not show evidence of metastatic CSCC. Conclusion: This case highlights a rare presentation of sporotrichoid lymphocutaneous spread secondary to CSCC. The differential diagnosis included infectious causes and metastatic CSCC. Surgical excision is the treatment of choice for high-risk CSCC. She presented with signs of metastasis at initial presentation but these were not recognized. At follow up, she rapidly developed signs of metastasis in an unusual pattern. As malignancy is a rare cause of sporotrichoid lymphocutaneous spread, it is important to raise awareness to physicians who may see sporotrichoid pattern to consider the possibility of malignancy in their differential diagnosis, especially when there is a history of malignancy or there is a concomitant visible mass present.Item Tapinarof-Induced Folliculitis Outside of Treated Psoriasis Plaques: A Case Report(2024-03-21) Martinez, Maria Francesca Ysabelle; Scheufele, Christian; Weis, StephenBackground: Tapinarof 1% cream is a novel non-steroidal topical medication recently FDA-approved for plaque psoriasis. Plaque psoriasis is a chronic inflammatory skin disorder that manifests as erythematous plaques with micaceous scale on the body, often associated with pruritus. Appearance and symptoms of the plaques can greatly impact patients’ quality of life. Tapinarof’s non-steroidal mechanism allow for longer treatment periods without topical corticosteroid side effects e.g. skin atrophy, hypopigmentation, telangiectasia, and striae. Adverse events identified during pivotal trials may not be completely defined before widespread clinical use. This case reports a new presentation of folliculitis with tapinarof use. Case Presentation: A 25-year-old female with trisomy-21 presented for a rash on her left lower leg. The eruption began one year earlier. The eruption was not associated with pruritus, joint pain or nail changes. A clinical diagnosis of plaque psoriasis was made. Due to unsuccessful response with topical steroids and topical vitamin D analogues, alternative treatment was started with topical tapinarof. After approximately two months of treatment, the patient presented with a new concern of an itchy rash. On exam she had follicular papules around the original plaque. In addition, she had follicular papules and pustules following a linear distribution ascending the affected leg. These papules were distant from the original eruption. There were similar scattered papules on the unaffected leg. A clinical diagnosis of folliculitis was made. Bacterial and fungal cultures were negative. A biopsy demonstrated folliculitis and special stains did not show organisms. Conclusion: Tapinarof cream is a novel non-steroidal treatment option for plaque psoriasis. Tapinarof is considered by many to have a better safety profile when compared to topical steroids. Adverse events reported in tapinarof clinical trials included folliculitis at or near the site of psoriatic /plaque. This case is unique as the folliculitis occurred not just at the site of application, but also occurred distant to the site. The distribution has not been previously reported. Our case provides histological confirmation of folliculitis as a side effect. This unusual distribution of folliculitis may be due to external factors such as transfer of the medication by bed sheets or clothing. An alternative theory may be scratching of the plaque then subsequent spread to the areas where folliculitis is now evident. Further experience with tapinarof will more completely define tapinarof associated folliculitis. In the meantime, clinicians treating patients with tapinarof who develop folliculitis need to consider this possibility in their differential diagnosis.