This article illustrates a web-based conversational learning system termed, “Virtual Grand Rounds in Dermatology” (VGRD), that was developed by two dermatologist colleagues from the United States and Malaysia, respectively, over the past decade. Two blog posts discussing the diagnostic uncertainty around possible dermatological manifestations of lupus are highlighted along with a few conversational comments from other health professionals. The posts, as they appear on VGRD are presented verbatim and illustrate a health professional narrated website that relies heavily on images and pattern recognition. We show that health professional learning may thrive on feedback from colleagues, even if minimal.
TopCase 1 (Ref To Vgrd Site)
Posted by author DJE
Evolving Lupus Variant?
Your thoughts are most welcome with regards to this patient. I don't have a firm diagnosis yet, but suspect this will turn out to be a form of lupus -- possibly subacute or acute LE.
HPI: A 47 year old woman was seen on June 11th, 2007 with a one month history of two 8 cm. plaques on her legs, KOH negative. Did not look like panniculitis. Initially thought to be Lyme disease, the lesions did not respond to doxycycline.
Because of progression of lesions and question of hypersensitivity disorder per biopsy the patient was treated with prednisone and the eruption subsided over a few weeks.
On 10 mg of pred a day, around 5 weeks after starting prednisone, the patient experienced a marked flare. This was during a long weekend at the beach. She said the weather was overcast and she wasn't out that much. Initial lesions recurred and there were some new papules and plaques on arms and legs. She has marked facial erythema and erythema of neck and upper chest. Other than pruritus, she feels well. No new meds.
Late August to Sept. 2007. Patient's eruption flared on legs and arms. On September 4, for the first time a definite butterfly rash on malar eminences. She feels well other than pruritus and has no arthralgias or constitutional symptoms. Sept. 5th, butterfly rash gone.
Figure 1. Erythematous plaques on case 1
Figure 2. Erythematous plaques on case 1
8/28/07 Repeat CBC (normal) ESR 17, ANA + anticentromere 1:360
9/4/07 Repeat CBC, PLT normal, ESR still 17
Pathology: 6/30/07
Mild epidermal spongiosis with focal lymphocytic exocytosis and mild to moderate superficial and deep perivascular and interstitial lymphohistiocytic infiltrate with scattered neutrophils and rare eosinophils, extravasated erythrocytes and papillary dermal edema .
Pathologist's Note: These changes are consistent with an allergic dermal hypersensitivity reaction with mild vasculopathy, and may be seen in erythema chronicum migrans . These are not the changes of erythema nodosum . The differential diagnosis includes, in the appropriate clinical setting, a drug eruption or a pigmented purpuric eruption . P.A.S. stain is negative for fungal organisms. Clinico-pathologic correlation is suggested.