新英格兰：疥疮和花斑癣
弥漫性皮肤黑变病
一 76 岁男性因逐渐疲劳不适入院。数周前皮肤开始灰蓝色变。由于皮肤颜色的明显变化，该患者与其身份证照差别明显。14 周前该患者确诊为黑素瘤，5 月前发现肝和脾转移。该患者皮肤的色素沉着是弥漫性皮肤黑变病的结果，预示预后不佳。http://www.nejm.org/doi/full/10.1056/NEJMicm1508394
气管支气管扩大
一 84 岁男性患者严重的主动脉瓣狭窄，为行经心尖主动脉瓣植入术入院。既往有慢性支气管炎和反复呼吸道感染史。气管内插管和袖带充气后，发现严重的气管漏气。诊断为气管支气管巨大症，即 Mounier-Kuhn 综合征。http://www.nejm.org/doi/full/10.1056/NEJMicm1508462
弗氏综合征
一 64 岁男性因下肢进行性无力一周来诊。神经系统检查示双腿瘫痪，L1 和 L2 水平以下感觉减退。因患者带有心脏起搏器，故无法行磁共振检查。脊柱 CT 检查示椎间盘病变。腰椎穿刺示脑脊液黄色、粘性，在试管内凝结。脑脊液中蛋白水平超过 1500 mg/dl，糖水平为 45 mg/dl。脑脊液中每毫升中不到一个有核细胞，革兰氏染色和细菌培养均为阴性。根据患者脑脊液中蛋白水平升高、黄染及高凝状态，诊断为弗氏综合征 （ Froin’s syndrome），可能由脊髓肿块阻塞脑脊液流动，并且发生脑膜刺激症状。http://www.nejm.org/doi/full/10.1056/NEJMicm1509557
疥疮
A 61-year-old woman presented with severe pruritic rash, which had been present for 6 months. Excoriated papules with honey-colored crusting were present on the abdomen, back (Panel A), arms, and legs. Treatment with fluocinonide cream and doxycycline for suppurative folliculitis and prurigo nodularis for a period of 4 weeks produced no resolution of the rash. A biopsy of the rash revealed mixed inflammatory infiltrate with eosinophils, which was suggestive of a drug-related rash. Discontinuation of all medications resulted in no change. Finally, skin scrapings from several web spaces on the hands (scabies preparation) showed a mite under light microscopy (Panel B). Topical permethrin cream that was applied overnight to the entire body and repeated in 1 week cleared the rash within 2 weeks after the first application. Scabies is a mite-borne disease characterized by pruritus that is classically worse at night. Untreated disease can be associated with extensive eczematization of the skin owing to constant scratching. Secondary infections such as impetigo, ecthyma, paronychia, or furunculosis can also occur. Clinically, burrows are difficult to visualize and may be disguised by excoriations and impetigo. Biopsy specimens often show nonspecific changes without burrows or mites, since patients may have only 6 to 10 mites on their entire cutaneous surface.http://www.nejm.org/doi/full/10.1056/NEJMicm1500116
花斑癣
A 24-year-old woman presented with a 12-year history of a depigmenting rash. The rash was most notable in the summer months, with remission during cooler seasons. She reported prominent scaling of her skin, particularly after showering. Over the preceding 2 to 3 years, the rash had spread to include her entire torso with extension down her arms. She was concerned that facial involvement might occur. Previous therapies with multiple topical antifungal agents had not regenerated skin pigmentation. Physical examination revealed large, coalescing, hypopigmented patches and macules on her torso and upper arms (Panel A) with scant scaling. A skin biopsy was performed to evaluate for vitiligo. Melan-A staining confirmed a normal presence of melanocytes (Panel B, arrows). Subsequent periodic acid–Schiff staining revealed the presence of yeast in a “spaghetti and meatball” pattern in the superficial epidermis (Panel C, arrow). A diagnosis of tinea versicolor was made. Scaling that results from stretching or scraping of the skin is suggestive of tinea versicolor and should prompt examination under the microscope, when possible, of skin scrapings treated with potassium hydroxide or chlorazol black E. Given the extensive skin involvement, the patient was treated with a course of oral fluconazole and topical ketoconazole; the patient was lost to follow-up. The process of skin repigmentation may take months once the fungal cause is eliminated.http://www.nejm.org/doi/full/10.1056/NEJMicm1501201
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