KHARKOV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF DERMATOLOGY, VENEROLOGY AND MEDICAL COSMETOLOGY

Case History Patient: Alexander Anatolivich Final Diagnosis: Chronic microbial eczema

STUDENT: ALMAZORY HASSAN 4TH COURSE DENTISTRY Date of treatment: Start:13-02-2013 Finish:20-02-2013

CASE HISTORY

I. PASSPORT DATA Name: Igor Anatolivich Age: 53 yrs Sex: male Birth date: 2nd August Marrital status: Married Address: Kharkov Occupation: retired (pension) Past occupation: worked as a transporter driver for 13 yrs. II. PATIENTS COMPLAINTS Patient complains on: Severe itching on the right hands and left leg Bad smell coming from the left leg Swelling of the left leg and pain upon pressure Discharge of fluids of yellow colour from the leg Dry , itching, red skin on the flexural areas of hands Water aggravates the condition and causes exudation

III.HISTORY OF PRESENT DISEASE 5yrs ago patient was admitted to stational department with a diffuse rash all over the body. Patient was treated and discharged. After a week the rash re occurred and patient was admitted again to the department. This time treatment was successful . Disease appeared again as a small red spot on the left leg 3 years ago. It progressed rapidly and became dry and itching together with a foul smell. IV. LIFE AND SOCIAL HISTORY Patient does not suffer from any inherited congenital diseases. No family history of diabetes , bronchial asthma, conjunctivitis, and chronic rhinitis. Currently the patient is a smoker of 1.5 packets of cigarettes per day, and consumes alcohol.

He does not suffer from any food or drug allergies , has no past operations.No similar symptoms of his disease are observed in any of his family members. V. OBJECTIVE EXAMINATION. General state: - Weight:60kg - Height:181 cm - Good condition with a clear consciousness - Calm facial expression - Active behavior - physical constitution: asthenic - Muscles are slightly under developed - Skin colour is slightly pale - Edemas of peripheral extremities on legs was observed.

Respiratory system - Breathing rate: 23 brpm - Percusssion of lung borders- dullness in intercostals spaces - Hyper reasonant sounds in comoparative percussion of lungs - Auscultation- dry rales on expiration - Spontaneous dyspnea occurring at rest position - No thorax deformations on palpation - Symmetric respiratory motion - No audible crepitations, rales on percussion and auscultation Cardiovascular system - Heart rate: 90bpm - Blood pressure 90/120 mmHg - Auscultation: irregular heart rhythm Systolic murmur on the apex of the heart - Percussion: dullness - Palpation of peripheral vessels seems to be normal Digestive system: - Oral cavity: pale cyanotic gingival Multiple caries Spontaneous bleeding of the gums Geographic tongue with ulcer 4 mm on lat side - Abdomen:slight abdominal distension with tenderness on palpation - Decreased peristaltic sounds - Liver: Normal - Kidney: Normal

Nervous System: - Normal orientation in space and time - Calm depressed behavior - Coordination of movement is normal - Sensory function:normal in all the sensory organs with decrease eye sight Endocrine system: - Thyroid gland:slightly enlarged Urogenital system: Kidney decreased in size and mobile on palpation Derease urinary output to 500 ml/d VI. STATUS LOCALIS Localization: macula, erythema located on the left leg and flexor surface of both arms(symmetric) Spots pinkish in color dry Left Leg Primary elements: erythema pink color, dry Shape:oval with irregular margins Borders:lost in normal skin Secondary elements: Hands Primary elements: rosella pink color, dry Shape:oval with irregular margins Clear borders localized on flexure surface of hands lots of crusts , wet easily removed scales yellowish itchy Warm on touch Peripheral healing with scaring and atrophy Foul smell

Secondary elements: few crusts , dry not easily removed scales yellowish severe itching .

VII. -

LABORATORY INVESTIGATIONS Complete blood count

(4.32-5.72 million cells/mcL**)

Red blood cell count 4.32-5.72 trillion cells/L*

Hemoglobin

13.5-17.5 grams/dL*** (135-175 grams/L)

Hematocrit

38.8-50.0 percent

White blood cells

13 x 109 WBCs per liter (L) White blood cell types (WBC differential) Neutrophil s: Band neutrophil s: 50% 3%-6%

Lymphocyt 25%-40% es: Monocytes 3%-7% : Eosinophil s: Basophils: 0%-3% 0%-1%

Platelet count

150-450 billion/L

Glucose level:6.5 mmol/l Dermographism:whight wassermann reaction test: negative ELISA for HIV: Negative Diascopy: white color followed by redness after removal of the glass VIII. HYPOTHETICAL DIAGNOSIS

Based on the anamnesis and the complaints of the patient and after further physical and clinical laboratory methods of investigation we concluded by the hopothetical diagnosis to be:

Chronic microbial eczema

IX Differntial diagnosis: Chronic microbial eczema can be differentiated with the following diseases: - Allergic dermatitis - Psoriasis - Occupational eczema

clinical signs of the patient

chronic microbi al eczema

psoriasi s

allergic dermati tis

occupat ional eczema

Macula Erythema Itchy foul smell Scales Erosions Scars whight dermat ographi sm leukocytosis yellowis h color of scales

+ + + + + + +

+ + + + + + +

+ + + + +

+/+ -

+ +

Psoriasis: Plaques of red, inflamed skin, often covered with loose, silver-colored scales. These plaques may be itchy and painful and sometimes crack and bleed. In severe cases, the plaques will grow and merge into one another, covering large areas.localized on the extensor surface

X Conclusion: 1. Not psoriasis because patient doesnt have silvery white scales on the extensor surfaces of limbs,

Contrary patient had yellowish scales with foul smell on flexor surface of the hands and leg 2. Not allergic dermatitis because patient doesnt have any allergic reactions in the past. Contrary he had yellowish scales with foul smell, white dermographism localized on the flexor surface of hands and leg 3. Not Occupational eczema because he has been working for more than 20 years and never had any complication due to his work according to the anamnesis. Contrary he had yellowish scales with foul smell, white dermographism localized on the flexor surface of hands and leg XI Final diagnosis: Based on all what was presented from anamnesis morbi(Reoccurrence of rash and appearance of red spot on the leg after successful treatment) ,anamnesis vitae, patient complaint(itchy and bad smell from left leg) , examination, and differential diagnosis we conclude that our preliminary diagnosis was the right one. Patient has chronic microbial eczema. XII Possible Complications A number of complications can arise with atopic dermatitis. Some are relatively common; others extremely rare: Hand dermatitis Skin infections Eye complications Exfoliative dermatitis Meningitis Septicemia Ulceration and gangrenose complication XIII Plan of treatment: Good skin care is a key component in controlling eczema. For some people with mild eczema, modifying their skin care regime and making a few lifestyle changes may be all that is needed to treat eczema. Other people with more severe eczema may need to take medications to control their symptoms. Non-drug treatments for eczema include: Mild soap and moisturizer. It's best to use a mild soap or soap substitute that won't dry out your skin. Gentle soaps, known as syndets, are available at the drugstore (brand names can be recommended by your doctor). A good moisturizer (in cream, lotion, or ointment form) helps conserve the skin's natural moisture and should be applied immediately after a shower or bath, as well as one other time each day. Some people with severe eczema may benefit from taking baths with a small amount of bleach

added to the water. The bleach helps to kill bacteria that lives on the skin of people with eczema. Short, warm showers. People with eczema should avoid taking very hot, or long showers or baths, which can dry out your skin. Reduce stress. Take steps to reduce stress. Get regular exercise and set aside time to relax. Medications and other treatments for eczema include: Hydrocortisone cream(Proctocort) Rp: Hydrocortisone 0.1% Signa. Use on effected part

Antihistamines.( Chlorpheniramine) Rp: Chlorphenamine 0.10% Signa. 10 mg daily intravenously

Corticosteroids.(Prednisolone) Rp: Prednisolone 0.10% S. 1 Tab daily Ultraviolet light therapy Immunosupressants. Immunomodulators.

XIV Prognosis: General patient prognosis after one week of treatment is good. Patient showed reduced signs and symptoms of disease. Expected date of release from stational department was on 21th February 2013. XV Epicrises Patient Igor Anatolivich was admitted in the stational department on 08th February 2013. He complained on foul smell from his left foot, a lot of erosions, scales, pain and crusts that were easily removed. Together with

that the patient also complained on severely dry , itchy and red skin on the flexor surfaces of both of his hands. After physical exam it was observed that the patient had leucocytosis in his blood count, white dermographism, yellowish scales, erosions and crusts, we were able to put a hypothetical diagnosis of chronic infectious eczema . The laboratory methods of investigations and differential diagnosis were finally able to conclude that our patient suffers from chronic microbial eczema. The patient was treated at the stationery department and a week later he showed good prognosis and signs of recovery. He was then released home from the clinic on 26th February 2013, with the correct measures and advice on his life style that will help him to prevent exacerbation and recurrence of his disease.

Literature
WWW.Drugs.com www.Wikipedia.com www.medescape.com www.emedicene.com www.webmd.com www.mayoclinic.com http://www.nlm.nih.gov/medlineplus/skinconditions.html