Clinical photos - Part 1

Despite the long hours and crazy patient load, I'm getting to see some amazing pathology. 

I saw this 14 year old girl who presented as a follow-up for "biopsy proven chronic mucocutaneous candidiasis", with a chart that was far thicker than I had seen for a patient that age. Her presentation was odd, though, as most of her body just looked like severe eczema. She had scaling of the scalp, however, with alopecia as well as granulomatous, infiltrated plaque on the nose, and coarse facies. Nothing about her struck me as normal and so I spent about 30 minutes leafing through her chart. I was planning on ordering Ig levels, anyway, but found that some helpful soul had already done it sometime in the past (2009). The only problem was, no one had commented on the fact that her IgE level was >4000 (all others normal). So she certainly did have chronic mucocutaneous candidiasis, as well as eczema, but more importantly, she had Job's Syndome! Job's syndrome (named after the long-suffering biblical figure) is also known as Hyper-IgE syndrome and presents with... wait for it... severe eczema, chronic mucocutaneous candidiasis, recurrent bacterial infections leading to granulomas, and coarse facies. Another curious finding with the syndrome is retention of the milk-teeth and when I asked her mother she said she kept her baby-teeth for a very long time and then they all fell out at once. Mystery solved! Too bad the person who ordered those Ig levels didn't follow up on them back in 2009. Here is a picture of her.

It's going to be a long road of prophylactic antibiotics, antifungals, and eczema therapy for her.

This is an unfortunate gentleman with vitiligo and photosensitivity related to HIV. The photosensitivity of HIV is very common in Botswana, but not something that I was familiar with until coming here. Notice in the photos the erythematous areas in a photo-exposed distribution. I thought it was interesting that there doesn't seem to be any improvement in the vitiligo in those areas. You would think that the inflammation from the photosensitivity would actually help the vitiligo but no such luck. Can't catch a break sometimes.

To end on a more positive note, on the right you can see a picture of a 101 year-old woman. I can't recall what her derm complaint was but I found it amazing that she hobbled her way into clinic all under her own power - no walker or anything. She wasn't too happy about the picture though, as you can see.

Updates haven't been too frequent lately as the internet has been very spotty, but I found an internet cafe near my apartment today so I will bring my camera back tomorrow and write some more.

Signing off, from Gabarone.