@schowardjd

Law | Medicine | @UF #GoGators, @GWAlumni, inter alia | 𝕏 ≠ legal/medical advice | Scientia quaesitor

 United States
Joined January 2009
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A woman in her 70s w/ peripheral vascular disease developed painful B/L leg purpura 5 days after thrombolysis & radial-access coronary stenting for STEMI. O/E: livedo racemosa, retiform purpura w/ central necrosis, & cool, dusky toes despite palpable pedal pulses & no large-vessel occlusion. CRP was 150 mg/L, & creatinine rose from 50 to 108 ÎŒmol/L. What’s your DDx❓
Livedo racemosa over the lower legs.

ALT Livedo racemosa over the lower legs.

Retiform purpura with angulated, branching borders over the thighs.

ALT Retiform purpura with angulated, branching borders over the thighs.

Dusky, cyanotic toes.

ALT Dusky, cyanotic toes.

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Dx: Guttate morphea (localized scleroderma). This rare superficial variant presents w/ multiple small, discrete sclerotic papules or patches, typically on the trunk & extremities. Bx confirmed dermal sclerosis w/ thickened, hyalinized collagen; elastic fibers were preserved, arguing against papular elastorrhexis. The absence of Raynaud phenomenon, sclerodactyly, & disease-specific autoantibodies argued against systemic sclerosis. Topical triamcinolone 0.1% ointment relieved pruritus, w/ initial progression followed by stabilization over several months. Guttate morphea can mimic extragenital lichen sclerosus & other papular dermatoses, making histopathologic confirmation important.
Low-power histopathology of a punch biopsy of the lesion on the arm demonstrating thickened sclerotic hyalinized collagen and loss of periadnexal fat extending from the superficial to mid dermis.

ALT Low-power histopathology of a punch biopsy of the lesion on the arm demonstrating thickened sclerotic hyalinized collagen and loss of periadnexal fat extending from the superficial to mid dermis.

Higher power of the aforementioned punch biopsy on the arm highlighting the thickened sclerotic hyalinized collagen in the superficial dermis.

ALT Higher power of the aforementioned punch biopsy on the arm highlighting the thickened sclerotic hyalinized collagen in the superficial dermis.

Scott C. Howard
@schowardjdOct 17
A teenage male presented with a 1-year hx of an initially pruritic eruption that began on the trunk & progressively spread across the trunk and B/L extremities, sparing the hands & feet. Lesions were skin-colored to ivory-white sclerotic papules w/ hyperpigmented brown borders & had become asymptomatic. He denied prior similar episodes, recent illness, travel, sick contacts, new meds, or recreational drug use. He had no hx or clinical evidence of Raynaud phenomenon. ANA, anti-SSB, anti-Scl-70, anti-ssDNA, anti-Smith, anti-Ro52/Ro60, & anti-RNP antibodies were unremarkable. What’s the diagnosis❔
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Generalized guttate morphea (a papular/generalized form of localized scleroderma).
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Dx: Brunsting–Perry pemphigoid (BPP). This rare, localized autoimmune subepidermal blistering disorder typically affects the scalp & head/neck, w/ recurrent bullae & erosions healing w/ scarring & usually sparing mucosal surfaces. Bx showed an eosinophil-predominant subepidermal blister, & DIF demonstrated linear IgG & C3 along the basement membrane zone. High-potency topical corticosteroids & doxycycline provided partial improvement; dapsone was discontinued due to transaminitis, & methotrexate was avoided due to intolerance concerns. Topical roflumilast (ZoryveÂźïž) 0.3% cream daily achieved complete clearance within 4 weeks, w/ sustained remission on monotherapy & no reported adverse effects. PDE-4 inhibition may offer a steroid-sparing option for localized BPP, although evidence remains limited to case reports.
Scott C. Howard
@schowardjdOct 21
A man in his late 80s w/ chronic actinic keratoses presented w/ a several-month hx of recurrent tense bullae & erosions on the scalp, L cheek, & supraclavicular region, healing w/ scarring. Pruritus was minimal, & mucosal involvement was absent. Scalp Bx showed a subepidermal blister w/ predominantly eosinophilic inflammation; DIF demonstrated linear IgG & C3 deposition along the basement membrane zone. What’s your diagnosis❔
Erosive & crusted erythematous plaques on the scalp w. a tense bulla & early cicatricial changes at baseline.

ALT Erosive & crusted erythematous plaques on the scalp w. a tense bulla & early cicatricial changes at baseline.

Microscopic photomicrography showing a subepidermal blister predominantly eosinophilic inflammatory infiltrate.

ALT Microscopic photomicrography showing a subepidermal blister predominantly eosinophilic inflammatory infiltrate.

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Brunsting–Perry pemphigoid (BPP) — a localized, scarring pemphigoid phenotype involving the head/neck, often considered within the mucous membrane pemphigoid/bullous pemphigoid spectrum. <@GeminiApp 4 Argon via @MedicalSphereAI>
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đŸ’›đŸ’œđŸŒ±A cluster of yellow Phalaenopsis (moth) orchid flowers with vibrant magenta & white centers.
Scott C. Howard
@schowardjd18h
đŸ’›đŸŒ± Golden calla lily (Zantedeschia elliottiana)
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Dx: Acute cutaneous kava toxicity presenting as a sebotropic neutrophilic pustular eruption. Recent kava tea ingestion preceded a diffuse pustular eruption w/ fever, facial edema, neutrophilic leukocytosis, & transaminitis. Bx showed subcorneal pustules & a folliculocentric, sebotropic neutrophilic infiltrate w/ sebaceous lobule destruction; microbial stains were -ve. Stable-dose fluoxetine was a less likely trigger given the temporal association w/ kava initiation. Kava was discontinued, & systemic glucocorticoids led to rapid resolution. This rare reaction shows the importance of eliciting herbal supplement use in patients w/ acute pustular eruptions & systemic abnormalities.
Histologic findings demonstrate destruction of a sebaceous gland by a dense infiltrate composed of lymphocytes and neutrophils (10× magnification; inset, 40× magnification).

ALT Histologic findings demonstrate destruction of a sebaceous gland by a dense infiltrate composed of lymphocytes and neutrophils (10× magnification; inset, 40× magnification).

Scott C. Howard
@schowardjdOct 16
A woman in her 20s w/ anxiety presented w/ an 8-day hx of a diffuse, pruritic eruption, fever, chills, & facial edema beginning after starting kava tea 2 wks earlier. O/E: widespread pustules on edematous erythematous plaques, w/ prominent periorbital edema & sparing of the palms, soles, & mucosae. Labs revealed neutrophilic leukocytosis & transaminitis (AST 232, ALT 355 U/L). She had been taking stable-dose fluoxetine for 3 mos. What’s the diagnosis❔
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đŸ’›đŸŒ± Golden calla lily (Zantedeschia elliottiana)
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if it doesn’t come bursting out of you in spite of everything, don’t do it. unless it comes unasked out of your heart and your mind and your mouth and your gut, don’t do it. - Charles Bukowski - đŸ–Œïž Snow Storm - Steam-Boat off a Harbour’s Mouth by J.M.W. Turner (1842).
Snow Storm - Steam-Boat off a Harbour’s Mouth exhibited 1842, Joseph Mallord William Turner This is one of Turner’s most daring paintings. In a battle between modern machine and nature, a steamboat faces a blizzard. Its black fumes join the whirling vortex of snow and sea. Turner claimed he ‘got the sailors to lash me to the mast to observe [the storm]...for four hours’. Although it can’t be proven, it shows that Turner wanted us to see this dizzying scene as an authentic record. When he heard it had been ridiculed as ‘soapsuds and whitewash’, he responded: ‘I did not paint it to be understood, but... to show what such a scene was like’.

ALT Snow Storm - Steam-Boat off a Harbour’s Mouth exhibited 1842, Joseph Mallord William Turner This is one of Turner’s most daring paintings. In a battle between modern machine and nature, a steamboat faces a blizzard. Its black fumes join the whirling vortex of snow and sea. Turner claimed he ‘got the sailors to lash me to the mast to observe [the storm]...for four hours’. Although it can’t be proven, it shows that Turner wanted us to see this dizzying scene as an authentic record. When he heard it had been ridiculed as ‘soapsuds and whitewash’, he responded: ‘I did not paint it to be understood, but... to show what such a scene was like’.

Holographic@HolographicMDOct 25
"if you’re going to try, go all the way. there is no other feeling like that. you will be alone with the gods and the nights will flame with fire." - "Roll the Dice", Charles Bukowski
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A man in his 60s w/ 5-y hx of suboptimally controlled T2DM presented w/ 3-mo progressive symmetric polyarthritis, morning stiffness >30 min, & digital paresthesias, followed by 2 mo of generalized pruritic skin thickening & waxy papules, then dysphagia. O/E: diffuse indurated plaques & firm, waxy papules on the face, neck, trunk, & proximal extremities, periorbital & pedal edema, +ve Shar-Pei & doughnut signs, & MCP/PIP synovitis. Dermoscopy showed rice-grain-like ivory-white structureless areas. Labs: CRP 24 mg/L, anti-CCP 71.91 U/mL; RF borderline -ve, ANA & SSc-associated Abs -ve. Hand radiographs & serial SPEP, serum IFE, and UPEP were unremarkable. Skin Bx showed dermal fibroblast proliferation, thickened collagen bundles, & abundant mucin on Alcian blue stain. What’s the diagnosis❓
Widespread firm, waxy, dome-shaped papules.

ALT Widespread firm, waxy, dome-shaped papules.

Doughnut sign.

ALT Doughnut sign.

10x H&E-stained histopath image illustrating marked fibroblast proliferation & thick collagen bundles throughout the dermis.

ALT 10x H&E-stained histopath image illustrating marked fibroblast proliferation & thick collagen bundles throughout the dermis.

Alcian blue staining demonstrating diffuse dermal mucin deposition.

ALT Alcian blue staining demonstrating diffuse dermal mucin deposition.

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A woman in her 60s presented w/ a 1-y hx of a persistent photodistributed eruption associated w/ hand arthralgias, fatigue, & ~30-lb weight gain. Topical clobetasol 0.05% ointment & clotrimazole provided no improvement. O/E: scattered annular papules & plaques on the dorsal hands, posterior neck, upper arms, & chest. ANA, TSH, CBC, CMP, HbA1c, & UA were unremarkable. What’s the diagnosis❓
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(1) Low-power examination demonstrates a dermal granulomatous infiltrate within a background of solar elastosis (H&E, ×40). (2) Higher-power examination reveals palisading lymphocytic inflammation with multinucleated giant cells in the dermis (H&E, ×100). (3) Colloidal iron stain highlights the absence of dermal mucin within areas of granuloma formation (colloidal iron, ×40).
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The fawns are shedding their spots, and it’s nice to see the two of them reunited.
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A tufted titmouse (Baeolophus bicolor) waits his turn at the feeder.
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A man in his late 80s w/ chronic actinic keratoses presented w/ a several-month hx of recurrent tense bullae & erosions on the scalp, L cheek, & supraclavicular region, healing w/ scarring. Pruritus was minimal, & mucosal involvement was absent. Scalp Bx showed a subepidermal blister w/ predominantly eosinophilic inflammation; DIF demonstrated linear IgG & C3 deposition along the basement membrane zone. What’s your diagnosis❔
Erosive & crusted erythematous plaques on the scalp w. a tense bulla & early cicatricial changes at baseline.

ALT Erosive & crusted erythematous plaques on the scalp w. a tense bulla & early cicatricial changes at baseline.

Microscopic photomicrography showing a subepidermal blister predominantly eosinophilic inflammatory infiltrate.

ALT Microscopic photomicrography showing a subepidermal blister predominantly eosinophilic inflammatory infiltrate.

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“The happiness of your life depends upon the quality of your thoughts: therefore, guard accordingly, and take care that you entertain no notions unsuitable to virtue and reasonable nature.” - Marcus Aurelius, Meditations - đŸ–Œïž Light and Colour (Goethe’s Theory) - the Morning after the Deluge - Moses Writing the Book of Genesis exhibited 1843, Joseph Mallord William Turner.
Pair to 'Shade and Darkness - The Evening of the Deluge'. This triumphant explosion of light brilliantly exploits the warm side of the spectrum. It celebrates God's Covenant with Man after the Flood. The serpent in the centre represents the brazen serpent raised by Moses in the wilderness as a cure for plague. Here it symbolises Christ's redemption of Man in the New Covenant. Turner's verses rather undermine the optimism of the religious message by emphasising the transience of the natural phenomena engendered by the 'returning sun'.

ALT Pair to 'Shade and Darkness - The Evening of the Deluge'. This triumphant explosion of light brilliantly exploits the warm side of the spectrum. It celebrates God's Covenant with Man after the Flood. The serpent in the centre represents the brazen serpent raised by Moses in the wilderness as a cure for plague. Here it symbolises Christ's redemption of Man in the New Covenant. Turner's verses rather undermine the optimism of the religious message by emphasising the transience of the natural phenomena engendered by the 'returning sun'.

Kalözol@kankulcayOct 21
DĂŒĆŸĂŒncelerinin rengiyle boyanır ruh... - Marcus Aurelius -
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A man in his late 50s w/ T2DM, HTN, HLD, & prior MI s/p coronary stenting presented w/ a progressive, pruritic eruption of the groin, gluteal region, & B/L axillae following travel to India & prolonged freshwater pond exposure. OTC topical clotrimazole provided no improvement. O/E: erythematous annular plaques w/ peripheral scale in the affected areas. Meds included aspirin, clopidogrel, prasugrel, metoprolol, & atorvastatin. What’s the diagnosis❓
Left upper chest showing erythematous scaly plaques evidence of linear post inflammatory hyperpigmented excoriations suggestive of intense itching.

ALT Left upper chest showing erythematous scaly plaques evidence of linear post inflammatory hyperpigmented excoriations suggestive of intense itching.

Right medial thigh with well demarcated, erythematous, and hyperpigmented, scaly plaques.

ALT Right medial thigh with well demarcated, erythematous, and hyperpigmented, scaly plaques.

Right inner thigh with well demarcated, erythematous, and hyperpigmented, scaly plaques. Lesions were pruritic and involved multiple body sites, including intertriginous areas, trunk, and extremities.

ALT Right inner thigh with well demarcated, erythematous, and hyperpigmented, scaly plaques. Lesions were pruritic and involved multiple body sites, including intertriginous areas, trunk, and extremities.

Medial buttock with multiple well-demarcated polycyclic, erythematous, hyperpigmented, scaly plaques, somewhat sparing gluteal cleft.

ALT Medial buttock with multiple well-demarcated polycyclic, erythematous, hyperpigmented, scaly plaques, somewhat sparing gluteal cleft.

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Dx: Cutaneous angiosarcoma of the scalp. An 85-year-old African American woman presented w/ a 1.5-y hx of a progressively enlarging scalp lesion that began as a small erythematous nodule after a fall and grew to ~10 cm. The DDx included pyogenic granuloma, angiosarcoma, melanoma, & fibrosarcoma. Angiosarcoma is an aggressive vascular malignancy that typically affects the scalp and face of older adults, with potential for extensive local spread, recurrence, and distant metastases. Tumor size is an important prognostic factor, underscoring the need for prompt biopsy, staging, and multidisciplinary management. <@GeminiApp 3.8 Flash via @MedicalSphereAI>
Scott C. Howard
@schowardjdOct 8
An 85-year-old African American woman presented w/ a 1.5-year hx of a progressively enlarging scalp lesion, initially a small erythematous nodule that developed after a fall. The lesion steadily enlarged to ~10 cm in diameter. She had no prior treatment, medications, or significant PMHx. What’s your diagnosis❓
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Bowen disease (squamous cell carcinoma in situ), arising in a field of actinic damage. <@GeminiApp 4 Argon via @MedicalSphereAI>
Scott C. Howard
@schowardjdOct 9
Spot diagnosis❓ Dermoscopy shows an erythematous background w/ micro-ulcerations, glomerular vessels, & superficial scaling. Polarized, non-polarized, and UV modes.
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