Episodic tender, warm, erythematous swelling of the extremity experienced by this patient is typical of erythromelalgia. Erythematous streaking on the volar surface of the left forearm (red arrow) and tender, warm, erythematous blanching swelling was present on the palmar hand (yellow arrow). Most patients with erythromelalgia also have lower extremity involvement including the dorsum or sole of the foot and toes.1
Close visual examination revealed erythematous linear papules on her upper and lower back. No bullae, drainage, or sloughing of the skin was present. The rest of her body, including palms, soles, and mucosa, was spared.
The images demonstrate a diffuse, flat, maculopapular exanthema along the torso, bilateral upper and lower extremities, and neck without edema consistent with reported cutaneous manifestations of COVID-19. There are no surrounding bullae, vesicles, or draining. On palpation, there was blanching of the rash. Sensation to light touch was intact in all extremities. The findings were also apparent on the face with no mucosal involvement.
The images show a raised, palpable, purpuric rash on the lower extremities, surrounded by a mild, 1+ non-pitting edema. Several of the lesions are exfoliated with serous discharge. There is no surrounding erythema, fluctuance, or lymphangitis to suggest cellulitis. There was no tenderness to palpation; however, pruritus was exacerbated on palpation.
Physical exam findings revealed vesicular lesions on the lip, hard and soft palates which did not cross the midline. The lesions appeared in the distribution of the maxillary branch (V2) of the trigeminal nerve, consistent with herpes zoster.
An asymmetric pattern of palpable purpura with bullae was noted on bilateral lower extremities with smaller patches on bilateral upper extremities. There was no tenderness or crepitus.
The first photograph demonstrates a dendritic blister (Lichtenburg figure) on the medial aspect of his right foot where the ground current injury entered the patient's foot. Although no data exists regarding the sensitivity or specificity of Lichtenberg figures as skin findings, they are considered pathognomonic for lightning injuries and are not produced by alternating current or industrial electrical injuries. The second photograph demonstrates a 4 x 3 cm area of petechiae where the ground current injury exited the patient.
Physical exam findings were significant for 1-3 cm diameter well-demarcated superficial ulcers on the patient’s abdomen and extremities, with mucosal sparing. Several small tense bullae were present on the bilateral inner thighs and numerous small reddish plaques were scattered over the patient’s back. Nikolsky’s sign was negative. No lymphadenopathy was noted.
The unilateral distribution of vesicular lesions over the patient's left naris, cheek, and upper lip are consistent with Herpes zoster reactivation with Hutchinson's sign. Hutchinson's sign is a herpes zoster vesicle present on the tip or side of the nose.1 It reflects zoster involvement of the 1st branch of the trigeminal nerve, and is concerning for herpes zoster ophthalmicus.1 Herpes zoster vesicles may present as papular lesions or macular vesicles on an erythematous base.2,3 Emergent diagnosis must be made to prevent long-term visual sequelae.4
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