The Bruiser from Cuba

The Bruiser from Cuba
J.A. Schneider, DO
Medical Director, Adolescent Medicine Mobile Health Outreach
St. Vincent Hospital - Jacksonville, FL
CAPT, MC, USN (Ret)
Asst. Professor, Division of Adolescent Medicine, University of Florida
(Ret)
Mike O’Log
•
7-year-old male transferred
to Naval Hospital Portsmouth
(Virginia) from Naval Hospital
Guantanimo Bay, Cuba for
evaluation of easy bruising
History
•
Mike had been perfectly well until 4 days
prior to these pictures when he was
taken to the pediatric clinic because new
bruises were of concern to his mother.
Mike O’Log ( continued )
History (continued)
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No bruising in the past; no nosebleeds
Platelet count in Cuba was 45,000 with a
normal CBC. BUT the platelet count was
245,000 with a normal CBC and normal
indices in our laboratory
Physical Examination
•
•
Afebrile; normal vital signs
Not ill-appearing… active, well nourished,
well developed
Mike O’Log
History (continued)
•
The past medical
history and review of
systems is entirely
non-contributory
Physical Exam:
• Bizarre linear
hyperpigmentation
without petecchiae
nor purpura
• No hepatosplenomegaly
The total picture…
no bruising… rather
strangely discolored
linear and whorled
hyperpigmentation.
The denuded area
under his left
areola looks like a
burn!
Linear hyperpigmentation
on Mike’s
forearms
Close-up of lesions on Mike’s abdomen
Let’s put this all together now...
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He doesn’t have leukemia
The bruising is bizarre.. like something
was smeared on his skin
The big question is,
“Could he have gotten
into something / played
with something that
would react with
his skin?”
fingers
palm
Close-up of lesions on Mike’s abdomen…
HEY!!!… that looks like a hand print!!!
I don’t want to leave you
hanging… the answer is...
•
•
Ask and ye shall find…
Mike and his buddies
were playing with limes
from the lime tree in his
back yard. Mike was
smearing the lime juice
on his skin…
So, Mike has...
Phytophotodermatitis or
“Lime Disease”
Phytophotodermatitis or “Lime Disease”
•
•
Fucocoumarins (psoralens), present in
limes that he played with, reacted with
the sunlight causing a photosensitive
reaction
Fucocoumarins are present
in a wide variety of plants
Plants containing Psoralens
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•
•
•
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Celery
Gas Plant
Meadow grass
Parsnip
Limes
Tomato
Angelica
Wild Angelica
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Cow Parsley
Carrots
Figs
Oranges
Bishop’s Weed
Hogweed
Rue
?? others
Now, let’s take a look at another
case of phytophotodermatitis
that presented as a case of
suspected child abuse...
•
•
•
Phillip Buster was being evaluated for the
sudden onset of unexplained burns.
There was seemingly no explanation and the
child protection team was called.
However, the attending in the clinic asked
the magic question...
Strange linear erythema on arms
Now, look again…
look very
closely...it almost
looks like
fingerprints on
Phillip’s left side
Phillip as he
presented in the
clinic
The magic
question was,
“Had Phillip been
playing with
limes?”
“Are you kidding?,” replied his mother.
“I was making Key-Lime pie and every
few minutes he would run through the
kitchen and I would pick him
up and put him outside to play.”
“He was driving me nuts!”
The crime is
reenacted by
Mrs. Buster
The crime is
reenacted by
Mrs. Buster
Case closed… another case of
phytophotodermatitis
References
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Phytophotodermatitis mimicking
superficial lymphangitis.
Br J Dermatol 2000 May; 142(5):1069.
Ahmed I; Charles-Holmes R
Phytophotodermatitis associated with
parsnip picking.J Accid Emerg Med 1999
Nov;16(6):453-4. Lutchman L; Inyang V;
Hodgkinson D
References
•
•
Phytophotodermatitis due to the
application of citrus hystrix as a folk
remedy. Br J Dermatol 1999
Apr;140(4):737-8 Koh D
Phytophotodermatitis.
Am J Contact Dermat
1999 Jun;10 (2):89-93
Bowers AG
References
•
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Phytophotodermatitis: the other
"lime" disease. J Emerg Med 1999
Mar-Apr; 17(2):235-7 Weber IC;
Davis CP; Greeson DM
Phytophotodermatitis mimicking
child abuse. J R Soc Med 1997
Oct; 90 (10):560-1. Hill PF;
Pickford M; Parkhouse N
References
•
•
Phytophotodermatitis. J Pediatr Health
Care 1997 Mar-Apr;11(2):84, 97-8 Bosch
JJ
Blistering of the hands and
forearms. Phytophotodermatitis.
Arch Dermatol 1995 Jul;131 (7):
834-5, 837-8 Webb JM;
Brooke P
References
•
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Phytophotodermatitis: a visit to
Margaritaville. Cutis 1993
Jan;51(1):41-2 Egan CL; Sterling G
An outbreak of
phytophotodermatitis due to
celery. Int J Dermatol 1994
Feb;33 (2):116-8 Finkelstein
E; Afek U; Gross E; Aharoni N;
Rosenberg L; Halevy S
References
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Phytophotodermatitis due to figs.
Cutis 1991 Aug;48(2):151-2
Watemberg N; Urkin Y
Phytophotodermatitis simulating
child abuse. Am J Dis Child
1985 Mar;139(3):239-40
Coffman K; Boyce WT;
Hansen RC
A nice review is at Emedicine.com
http://emedicine.medscape.com/article/11
19566-overview