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Case of the Month - January 2019

Case courtesy of: Nithendra Manickchund, Pariva J. Chutterpaul, Sonal R. Verma, Bernadett I. Gosnell, M. Yunus S. Moosa.

Department of Infectious Diseases, Nelson R. Mandela School of Medicine and King Edward VIII Hospital, Durban.

Written consent was obtained from the patient to publish images.

A 41-year-old woman presented to King Edward VIII hospital acute medical unit with a four-month history of progressive skin lesions. The lesions started on her face and gradually progressed to involve her trunk and arms. In the three weeks prior to admission, she developed constitutional symptoms and a productive cough. An HIV ELISA test was positive; she had never tested for HIV in the past. She denied a headache, visual disturbance or photophobia.

Social History:

She had worked in Hong Kong as an entertainer at an amusement park. She had travelled at least twice a year between Hong Kong and South Africa over the past three years. The skin rash began during her last trip to Hong Kong and worsened on her return to South Africa four months ago.

She had no significant past medical history or allergies. She was not using any medication.

Examination findings:

Notable findings were a temperature 37.2oC and significant conjunctival pallor. There was discrete rubbery cervical and supraclavicular lymphadenopathy, the largest nodes measuring 2.5 cm x 2 cm.

On skin examination there were multiple ulcerating papules that coalesced to form plaques with areas of haemorrhage and scabbing. Lesions were of varying sizes and ages. Early-stage papular lesions were centrally umbilicated. Lesions involved her face, upper arms, back and chest and a few lesions were noted on both thighs.

She was not distressed, with a respiratory rate 18 breaths/minute, and crepitations in the right middle zone anteriorly.

Her liver was soft and could be palpated 3 – 4 cm below the costal margin, with a total span of 16 cm. There was no splenomegaly or ascites.

Cardiovascular and neurological examinations were normal.

Unfortunately all of the patients X-rays were lost due to problems with the porters at the hospital.

Initial Blood Results
Full Blood Count Reference Range Urea and Electrolytes Reference Range Liver Function Test Reference Range CD4 T-cell Count Reference Range
WCC 5.5 4-10 x109/uL Na 131 136-145 mmol/L Total protein 71 60-78 g/L 5 332-1642 cells/mm3
Hb 8.2 12-15 g/dL K 4.1 3.5-5.1 mmol/L Albumin 18 35-52 g/L CD4% 3.89% 28-51%
MCV 85 83-101 fL Cl 93 98-107 mmol/L Total bilirubin 15 5-21 umol/L    
MCH 27.5 27-32 pg Bicarbonate 26 23-29 mmol/L ALT 55 7-35 U/L HIV viral load  
Platelets 221 150-400 x109/uL Urea 4.3 2.1-7.1 mmol/L ALP 63 42-98 U/L 165000 RNA copies/mL (5.22 log)  
    Creatinine 72 49-90 umol/L GGT 53 <40 U/L    

Differential: Neutrophils: 4.85 x 109 (88%) Lymphocytes 0.6 x 109 (10%)

Smear: Scanty teardrops, moderate anisocytosis, moderate polychromasia, dimorphic red cell picture. No yeasts seen.

Nov 2018 Figure 1
Figure 1: Lesions on the face on presentation (12 May 2018)
Nov 2018 Figure 2
Figure 2: Lesions on the upper arm at presentation demonstrating a polymorphic rash with lesions at varying stages of evolution. (12 May 2018)


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