| Introduction: | ||||
| A 60 year old male with a history of insulin dependent diabetes mellitus (IDDM) was evaluated by the inpatient dermatology consultation service for edema and blisters on the lower extremities of one month duration. | ||||
| History: | ||||
| A 60 year old man was admitted to the hospital following a week of worsening fever, dyspnea, cough and lower extremity edema. His past medical history was significant for IDDM, chronic renal insufficiency, hypertension, obesity, hyperplipidemia, gout, and supraventricular tachycardia. He also complained of blisters that appeared on his legs one month before admission. | ||||
| Clinical Presentation: | ||||
| On examination, there was pitting edema of both lower extremities below his knees. On the left shin he had a ruptured bulla that was partially healed with atrophy and a central hemorrhagic crust. Many smaller tense vesicles surrounded the bulla. On the right shin a large flaccid bulla was surrounded by vesicles some with central necrosis. | ||||
| Pathology: | ||||
| Histopathologic examination of a punch biopsy from a bulla on the right pretibial area showed a subepidermal bulla which was filled with serofibrinous material. The papillary dermis showed hyalinization and festooning of the dermal papillae. Within the papillary dermis, there was vascular proliferation with a perivascular lymphocytic and neutrophilic infiltrate. Rare eosinophils were also identified. | ||||
| Question 1: | ||||
| What is the differential diagnosis of a blistering dermatosis is this setting? | ||||
| Question 2: | ||||
| What further labs or studies need to be performed for further evaluation? | ||||
| Question 3: | ||||
| How would you treat this patient? | ||||
