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Medical arithmetic: Unusual ear, nail and skin conditions

What do these presentations add up to? By Dr Keith Hopcroft

CASE EASY

The patient
A 62-year-old man with a history of osteoarthritis and type 2 diabetes, controlled with metformin.

He says
I had a spot on my ear a couple of weeks ago, which I’ve scratched. Now the whole ear is swollen, hot and very painful. It hurts if I touch it and I can’t lie on that side. I feel a bit grim in myself and I think I have a fever.’

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Inflamed_ear_of_elderly_man_with_perichondritis

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See end of article for answer

CASE MODERATE

The patient
A 58-year-old man with GORD, eczema and mixed anxiety and depression, treated with lansoprazole, hydrocortisone cream and sertraline.

He says
‘I’ve had these ridges on my thumbnails for months. They don’t hurt but I don’t like them. A pharmacist said it was a calcium deficiency. Another thought it was a fungal infection. But supplements and creams don’t help.‘

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Median_nail_dystrophy

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See end of article for answer

CASE HARD

The patient
A 35-year-old man with a history of hypothyroidism who is taking levothyroxine.

He says
‘I’m getting fed up with this rash. I’ve been seen repeatedly over the past year and everyone has a different diagnosis. I’ve been told it’s eczema, psoriasis and scabies. But none of the treatments has helped, it keeps coming back and the itching is driving me mad. I’m getting it on my knees, too.’

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Dermatitis_herpetiformis

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See end of article for answer


Dr Keith Hopcroft is Pulse’s medical adviser and a GP in Basildon, Essex


Answers
EASY Auricular perichondritis This is an inflammation of the connective tissue surrounding the ear cartilage. It is often seen after cosmetic piercing through the cartilage – though in this case, it was probably secondary to the scratched bite or spot. These infections need to be treated aggressively with antibiotics – ciprofloxacin is first line. If an abscess develops it must be referred urgently for incision and drainage.
MODERATE Median nail dystrophy This results in a mid-line ridge, typically in one or both thumbnails. There may be transverse ridges, too, in an ‘inverted fir tree’ pattern. The cause is unknown but thought to be linked to trauma to the proximal nail fold. It is not associated with systemic disease or deficiency, and is not a fungal infection. No specific treatment is required, and the problem may resolve, though it can take months or even years.
HARD Dermatitis herpetiformis This is a very itchy condition causing a blistering rash over the extensor surfaces. Excoriation may disguise the blistering nature of the original lesions. Around 90% of cases are associated with gluten intolerance, and it may be associated with other autoimmune disease (such as autoimmune thyroiditis, as in this case). A gluten-free diet should lead to resolution.

Please note – these are all fictional cases and not based on any real patient interactions