United States

“CHRONIC WOUND MANAGEMENT AND SOCIOECONOMIC BARRIERS IN A STREET MEDICINE SETTING”
Jesse Obregon, Taha F. Rasul, Brittany J. Blake, Orly Morgan, Julie Schnur, Armen Henderson
Miami Street Medicine Institute, University of Miami Miller School of Medicine


Background
Persons experiencing homelessness (PEH) have decreased access to longitudinal care which means that they often present to providers in advanced disease stages. Street Medicine providers in low resource settings should consider cost-effective methods of managing patients with chronic wounds in order to prevent the development of complications. We present two cases in which Street Medicine providers used physical exam findings and a multifaceted approach to manage chronic wounds of differing etiologies. 
Case Presentation
Patient 1: A 53-year-old male was seen with multiple, acute and chronic facial wounds. He had been hospitalized multiple times in the past year due to seizure activity. He had been prescribed Levetiracetam, however did not take the medication due to side effects and limited access to refills. 
The street medicine team provided wound care, counseled on medication adherence, and coordinated an appointment at a nearby low-income clinic. Two weeks later, he had refilled his medication and did not have any further facial or bodily trauma. 
Patient 2: A 65-year-old unsheltered male with a history of liver disease was encountered for left leg non-healing ulcer. He was hesitant to receive care at any clinical setting. Initially, the wound was approximately 12 x 9 cm in size with purulent drainage and foul odor. Wound care provided consisted of saline irrigation, gentle debridement, bandaging, and multivitamin tablets. He was also provided with wound care supplies for self-service. Over the next 6 months, his wound shrunk to 8 x 7.5 cm in size with the presence of granulation tissue without erythema or malodorous discharge.

Discussion
The first case demonstrates how monitoring facial wound healing processes served as a clinical marker of seizure disorder improvement. Connecting that patient to primary care by leveraging community resources and medication refills helped in the improvement of his seizure disorder. The second case provided a challenge as the patient was resistant to help for his wound care and medical condition. Consistent wound care likely decreased the risk of severe complications such as cellulitis, osteomyelitis, and abscesses. Street medicine organizations can serve as a bridge for PEH from the street to the clinical setting. 


2022 AMA Research Challenge

Chronic Wound Management And Socioeconomic Barriers In A Street Medicine Setting

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Cutaneous Mycobacterium abscessus infection following injection of a lipolytic agent

Background: Nevus Sebaceous (NS) is a congenital hamartoma characterized by orange to skin-colored verrucous plaques typically of the scalp, face, forehead, or neck. Numerous publications report cases of secondary neoplasms arising from NS plaques including trichoblastoma, syringocystadenoma papilliferum, and basal cell carcinoma. In some exceptional cases, poroma–adnexal tumors of the intraepidermal sweat gland duct–have been reported to arise in NS plaques. 
Case Presentation: A 56-year-old man presented to the dermatology clinic with a brown pedunculated verrucous plaque overlying scattered irregularly shaped dark-brown plaques. The pedunculated plaque was biopsied for histopathological evaluation and showed benign adnexal neoplasm with eccrine differentiation most consistent with a pigmented eccrine poroma. A wide-local excision for complete lesion removal and further histologic examination was performed. The second biopsy revealed focal areas of acanthosis and papillomatosis with sebaceous gland hyperplasia consistent with nevus sebaceous. 
Discussion: Upon literature review, there are seven documented cases of poroma growth within a NS, four of which are eccrine poromas. In comparing cases, clinical differences including distinct morphologies of NS and EP plaques, and coexisting neoplasms can be observed. To this degree, our case might offer insight into the unique and rare presentation of secondary EP plaques arising from primary NS lesions. 


Eccrine Poroma Arising within a Nevus Sebaceus

Background
Harlequin sign is a rare disorder of the sympathetic nervous system with a noteworthy clinical presentation. Disruption of T2-T3 sudomotor and vasomotor innervation manifests as a unilateral facial paleness and anhidrosis with compensatory flushing and hypersudation contralateral to the site of injury. Horner’s syndrome is commonly associated, which involves interruptions to the T1 oculomotor sympathetic neurons resulting in ptosis, pupil constriction, and lack of sweating ipsilaterally. Recognition of these clinical presentations is essential in determining appropriate workup. 

Case Presentation
An 81-year-old female with a history of metastatic lung cancer presented with right-sided flushing predominantly in a V1 and some V2 dermatomal distribution, sharply demarcated at the midline. Notably, the patient also had left pupillary miosis and left partial ptosis, although no asymmetric anhidrosis. Her review of systems was negative for pruritus, pain, tingling, burning, blistering of the skin, which argues against zoster. She denied any neuropathic symptoms, changes in vision, flushing when eating, or prior procedures to the face that might otherwise suggest Frey syndrome. Given the clinical findings, this condition was likely secondary to a mass effect from a left upper lobe lung tumor, which measured 11.0 cm with encasement of the left common carotid artery and posterior elements of T1 and T2 segments on MRI. The patient continued treatment for her underlying malignancy and her symptoms improved.

Discussion
Diagnosis relies on a thorough medical history and physical exam. A brief exercise test or heat exposure can also induce symptoms in the clinic. Cervical MRI scans may further elucidate the primary cause, which can be idiopathic, congenital, iatrogenic, or organic, such as surgical procedures or a mass in the cervical region. Thus, the underlying primary cause should be the focus for treatment management and symptoms may subsequently resolve on their own. Interventions such as botulinum toxin injections or sympathectomy can be recommended if flushing or sweating negatively affects social life. Although this patient already had a known history of malignancy, such cutaneous signs may manifest as the first presenting sign of internal disease and should prompt physicians to assess for the underlying etiology and consider imaging to rule out malignancy.


Harlequin Sign Associated with Horner's Syndrome

Histopathologic analysis of debulk specimens in Mohs micrographic surgery (MMS) may augment high-risk factor identification in cutaneous squamous cell carcinoma (cSCC), leading to tumor upstaging. Existing studies have yet to comment on the location of high-risk factors within tumors. Herein we report four cSCCs initially categorized as well-differentiated that were reclassified to moderate to poorly differentiated on debulk analysis and upstaged accordingly. In all cases, the deep tumor margins displayed morphological differences from other areas, exhibiting less differentiation and/or perineural invasion. Thorough inspection of the deep tumor margins may be required for accurate tumor staging and evaluation of metastatic risk. 

Case Series
Patient 1: An 80-year-old male presented with a 2 cm plaque on the frontal scalp. Biopsy revealed well-differentiated cSCC staged at T2a with Brigham and Women’s Hospital Staging System (BWH), subsequently upgraded to T2b during MMS due to galea involvement. Debulk analysis revealed moderate to poorly differentiated cSCC with the least differentiated cells at the deep margin.
 
Patient 2: A 75-year-old male presented with a 2 cm plaque on the left vertex scalp. Biopsy revealed well-differentiated cSCC staged at T2a (BWH), subsequently upgraded to T2b during MMS due to extension beyond subcutaneous fat and PNI. Examination of the second stage revealed moderately differentiated cSCC with the least differentiated cells at the deep margin.
 
Patient 3: An 86-year-old female presented with a 2.4 cm nodule on the right lower leg. Biopsy revealed well-differentiated invasive cSCC. Debulk analysis revealed moderately differentiated cSSC with the least differentiated cells at the deep margin.

Patient 4: An 82-year-old male presented with a 2.7 cm nodule on the vertex scalp. Biopsy revealed well-differentiated cSCC staged at T2a (BWH), subsequently upgraded to T2b during MMS due to extension beyond subcutaneous fat. Debulk analysis revealed moderate to poorly differentiated cSSC with the least differentiated cells at the deep margin in the galea.

cSCCs may exhibit intratumor heterogeneity in which predominantly well-differentiated tumors contain focal areas of poorer differentiation. Intratumor heterogeneity complicates tumor risk estimation as a well-differentiated tumor on biopsy may exhibit poor differentiation at a deeper margin. Thus, the most clinically relevant cells for prognosticating risk may not be visible on biopsy, underscoring the utility of close examination of the debulk specimen and deep margin of the Mohs layer. Despite this, most Mohs surgeons endorse immediately discarding debulk specimens without evaluation. These cases reinforce that tumor staging is incomplete until the deep margins are assessed to find the most dysplastic cells.

Inspection of Deep Tumor Margins in Mohs Micrographic Surgery for Accurate Cutaneous Squamous Cell Carcinoma Staging

Pretibial myxedema (PTM), more generally thyroid dermopathy (TD), results from mucopolysaccharide accumulation in the dermis, typically between the knee and dorsal foot. TD presents in Graves disease, but can occur in Hashimoto’s thyroiditis, primary hypothyroidism, and euthyroid patients. Treatment of thyroid eye disease (TED) with teprotumumab is established in the literature, with few case reports also showing improvement in PTM. Reported is a 76-year-old male with TED and PTM treated with teprotumumab with improvement in both conditions. He developed “muffled” hearing as an adverse effect, a complication not widely published in the dermatology literature. At 13 months post-treatment, his symptoms are stable without recurrence, but hypoacusis persists. Given the long-term efficacy and side-effects, dermatologists should recognize the potential benefits and risks of using teprotumumab for TD. A baseline audiogram may be considered prior to therapy. Additionally, longitudinal data is needed to document the benefits and risks of this novel therapy.

Novel teprotumumab treatment of severe thyroid dermopathy; ototoxicity as an adverse effect

Here we describe the case of a Black adolescent patient who was found to have widely metastatic melanoma originating from a primary vulvar lesion. The lesion presented as a pink, vegetative nodule with asymmetric borders of the clitoral hood which had grown gradually in size over several years and was confirmed to be melanoma on shave biopsy. This patient’s amelanotic presentation in conjunction with the rare incidence of vulvar melanoma contributed to the delay in identification of the malignancy. This case exemplifies the challenge of early recognition of potentially malignant vulvovaginal lesions for primary care providers, especially in pediatric patients where melanomas often present with atypical features.

Primary vulvar melanoma in an adolescent patient

Background
Since 2000 the incidence of syphilis in the United States has increased by over 400%. Classically, secondary syphilis presents as a generalized, non-pruritic, maculopapular rash, often including the palms and soles. However, due to the wide range of mucocutaneous presentations, secondary syphilis is often called ‘The Great Imitator.’ Herein, we report an unusual presentation of secondary syphilis to remind physicians to consider this diagnosis. 

Case Presentation
A 39-year-old female with a history of Hepatitis B presented with a two-month history of numerous tender, crusted, erythematous papules on the face and neck, as well as superficial ulcerations on the tongue, posterior oropharynx, and lower mucosal lip. The lesions first appeared around her nose and mouth after wearing a new cloth mask and then spread more broadly across her face and neck. She had previously been treated with courses of acyclovir and methylprednisolone with no improvement. A seven-day course of sulfamethoxazole-trimethoprim 800mg-160mg resulted in partial healing of some of the lesions. She also endorsed hoarseness and a sore throat but denied additional systemic symptoms, sick contacts, or recent travel. Our differential diagnoses included: sarcoidosis, deep fungal infection, bullous impetigo, Majocchi's granuloma, cutaneous tuberculosis, cutaneous lymphoma, and lupus.
Punch biopsies revealed superficial and deep dense lymphoplasmacytic infiltrate with spirochetes seen in the epidermis on H&E. The rapid plasma reagin titer was reactive (1:4), and anti-Treponema pallidum IgG was positive, confirming the diagnosis of secondary syphilis. The patient was treated with an intramuscular injection of Penicillin G benzathine resulting in complete resolution of the lesions.

Discussion
The incidence of syphilis infection has been increasing in the United States in recent years. The case described herein demonstrates the importance of including secondary syphilis, an infection that often masquerades as others, in the differential when sexually active patients present with mucocutaneous lesions. Rapid identification is essential to combat this increasingly prevalent infection in the United States, through expeditious treatment and effective contact tracing. 


The Great Imitator: an unusual presentation of secondary syphilis

A case of Serotonin syndrome due to the concurrent use of Sertraline, Trazodone, and 
Quetiapine

Open globe ruptures are a common sight-threatening trauma consisting of decreased vision, loss of anterior chamber depth, irregularly shaped pupil, 360-degree subconjunctival hemorrhage, and prolapse of uveal tissue. The delayed presentation further complicates the return of vision with infectivity, and autoimmune pathology, and increases the likelihood of enucleation.

A Man with Traumatic Vision Loss: A Case Report

Abstract Title: Myocarditis preceded by hemolysis secondary to a Loxosceles reclusa bite
Background: Envenomation from the brown recluse spider (Loxosceles reclusa) can cause significant tissue damage or severe systemic illness, primarily potentially fatal hemolysis and renal failure. Few cases demonstrate loxoscelism-induced myocarditis. We present a case of loxoscelism with hemolytic anemia and myocarditis leading to cardiogenic shock and respiratory failure requiring mechanical ventilation.
Case Presentation: A previously healthy 18-year-old man presented to the emergency department with a one-day history of pleuritic chest pain and fever and was discharged with a diagnosis of viral syndrome after an unremarkable workup. He returned to the ED three days with a new morbilliform rash, dark urine, and painful right scapular lesion which reportedly began 5 days earlier. He was initially febrile and hypotensive to 59/49 and was admitted to the intensive care unit. On hospital day two, he had worsening tachycardia and hypotension. Electrocardiogram showed diffuse ST-segment elevation. Troponin peaked at 2.51 ng/mL. Transthoracic echocardiogram showed a maximally depressed ejection fraction of 28%. Respiratory failure ensued requiring intubation and mechanical ventilation. His Coombs positive hemolytic anemia had a hemoglobin nadir of 7.6 g/dL. An ELISA test of the scapular wound (SpiderTek, Rolla, MO) confirmed Loxosceles reclusa venom. By hospital day five, the patient was weaned from inotropes and extubated. He did not receive IV steroids, IVIG, or plasmapheresis. A repeat echocardiogram was normal. The patient was discharged on hospital day nine with a diagnosis of myocarditis.
Discussion: This is the third report of myocarditis associated with loxoscelism, the second case confirmed with a positive test for Loxosceles venom, and the first with an acute course requiring ventilator support. These studies include two cases of cardiac magnetic resonance-confirmed myocarditis. A direct cardiotoxic Loxosceles species venom has been previously demonstrated. Additionally, Interleukin 6, known to be elevated in loxoscelism, is associated with severe myocarditis. The abrupt decrease in cardiac function in an otherwise young, healthy patient, followed by rapid recovery, is consistent with toxin-mediated myocarditis caused by L. reclusa envenomation. Providers should be aware that recluse spider bites can cause life-threatening myocarditis and should tell all patients with recluse bites should seek immediate medical attention for dark urine.

Chronic Wound Management And Socioeconomic Barriers In A Street Medicine Setting

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