| Introduction: |
| A 50 year-old man was evaluated in dermatology clinic for easy bruisability and blistering of the tops of his hands.
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| History: |
| Bruising of his hands started 6 months earlier, and he recently developed painful itchy blisters in the same areas.
His history is significant for heavy alcohol use and occupation as a window installer. His review of systems and past medical history were otherwise non contributory. The patient was on no prescriptions or over the counter medications. He had no history of fevers, chills, night sweats or other recent illness. |
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| Clinical
Presentation: |
| Physical examination revealed marked sun damage particularly of the face and ears. Flaccid bullae were seen on the hands and fingers along with milia and crusted flesh colored to erythematous papules and plaques. Similar lesions were noted on both elbows. The remainder of the examination was significant for a liver edge that was palpated 2 cm below the right costal margin. |
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| Pathology: |
| Low power examination of a skin biopsy of the hand shows an intact epidermis and a subepidermal blister with only minimal inflammatory infiltrate. There is festooning of the papillary dermis (dermal papillae protruding into the blister from below). Higher power reveals thickening of the basement membrane and hyalinized superficial vessels. PAS stain demonstrates the homogeneous material in the basement membrane and dermal capillaries particularly well. |
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| Question
1: |
| What is the differential diagnosis for this patient, with specific attention to the subepidermal blisters on the dorsal hands without mucosal involvement? |
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| Question
2: |
| What labs tests could you send to establish the diagnosis? |
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| Question
3: |
| Are there additional tests you would send for possible associated diseases? |
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