Can You Identify the Cause of These Puzzling Symptoms?
Case 1: Extensive Ecchymoses Following a Fall
STEVEN R. SCHUBERT, MD
Vernon Hills, Illinois
A 72-year-old man slipped and fell backward in the bathroom, hitting his head on the toilet seat; he suffered only minimal discomfort. The following day, he presented with mild back pain and extensive bruising.
Impressive ecchymoses extended from his left flank to his right flank, across the midline, where a tender mass was palpated. Swelling was visible from a distance at the L4 level; the 17 × 10-cm lesion was raised approximately 1.5 cm, with overlying black-blue ecchymoses. The patient was taking self-prescribed baby aspirin, 81 mg/d; vitamins C, E, and B12; and Ginkgo biloba, 400 mg/d.
Could the fall alone have caused this extensive bruise—or is something else involved?
(Answer and discussion on next page)
ANSWER—Case 1: Aspirin and Ginkgo biloba
Because of the severity of the bruising, a noncontrast CT scan of the abdomen was obtained. The scan revealed a soft tissue mass (a hematoma) within the subcutaneous fat that extended to the adjacent muscle plane of the lower back; no intra-abdominal or retroperitoneal bleeding was noted. The patient was advised to discontinue both the aspirin and the ginkgo.
Ginkgo, or Ginkgo biloba, is known by several names, including ginkgo leaf, maidenhair tree, kew tree, fossil tree, ginkyo, yinhsing, Japanese silver apricot, Ginkgo folium, Salisburia adiantifolia, and bai guo ye. Ginkgo has long been used in folk and Chinese medicines for its purported psychotropic and neurotropic properties and as a sexual performance enhancer, premature aging preventative, antacid, antihypertensive and heart disease treatment, and liver function aid.1,2 Ginkgolide B, one of a group of terpenes contained in Ginkgo biloba and a known inhibitor of platelet-activating factor, is thought to cause some of the beneficial as well as some of the detrimental effects of ginkgo.3
Many adverse effects and interactions have been attributed to ginkgo, including bleeding dyscrasias, which have resulted in subdural hematoma4 and subarachnoid hemorrhage5; skin allergy; phlebitis; mild GI complaints; headaches; dizziness; palpitations; diarrhea; nausea and vomiting; loss of muscle tone; weakness; perioral erythema; rectal burning; and painful anal sphincter spasms.1,2 Generalized convulsions after consumption of a large number of ginkgo nuts, coma in a patient with Alzheimer disease who was taking low-dose trazodone and Ginkgo biloba, and postoperative bleeding after laparoscopic cholecystectomy in a patient who consumed ginkgo have been reported.6-8
After 3 weeks, this patient’s ecchymoses had resolved, but a 20 × 18-cm hematoma was still palpable. In time, the hematoma cleared without treatment; the patient has had no further episodes of bleeding.
(Next Case on Next Page)
REFERENCES:
1.Jellin JM, Batz F, Hitchens K. Natural Medicines Comprehensive Database: Pharmacist’s Letter/Prescriber’s Letter. Stockton, Calif: Therapeutic Research Faculty; 1999.
2.DerMarderosian A, ed. Guide to Popular Natural Products. St Louis: Wolters Kluwer Company; 1999.
3.Chung KF, Dent G, McCusker M, et al. Effect of a ginkgolide mixture (BN 52063) in antagonising skin and platelet responses to platelet activating factor in man. Lancet. 1987;1(8527):248-251.
4.Rowin J, Lewis SL. Spontaneous bilateral subdural hematomas associated with chronic Ginkgo biloba ingestion. Neurology. 1996;46:1775-1776.
5.Vale S. Subarachnoid haemorrhage associated with Ginkgo biloba. Lancet. 1998;352:36.
6.Miwa H, Iijima M, Tanaka S, Mizuno Y. Generalized convulsions after consuming a large amount of gingko nuts. Epilepsia. 2001;42:280-281.
7.Galluzzi S, Zanetti O, Binetti G, et al. Coma in a patient with Alzheimer’s disease taking low-dose trazodone and gingko biloba. J Neurol Neurosurg Psychiatry. 2000;68:679-680.
8.Fessenden JM, Wittenborn W, Clarke L. Gingko biloba: a case report of herbal medicine and bleeding postoperatively from a laparoscopic cholecystectomy. Am Surg. 2001;67:33-35.
Case 2: Discomfort and Occasional Pain of the Upper Arm
KOFI CLARKE, MD
Pittsburgh, Pennsylvania
A 59-year-old woman with a history of extensive psoriasis, hypertension, and obesity had experienced discomfort and occasional pain in her left upper arm for several months. She denied recent trauma. The physical examination revealed variable, nonspecific, mild tenderness along the left upper arm.
What do you suspect is responsible for the discomfort?
(Answer and discussion on next page)
ANSWER—Case 2: Migration of the tip of a broken needle
On further questioning, the patient reluctantly told of having used intravenous drugs many years earlier. Subcutaneous infection and migration of the tip of a broken needle were considered in the differential. Radiographs of the affected arm demonstrated a needle tip in the soft tissue (A and B, arrows); no signs of active infection were noted.
The patient refused surgery to remove the needle tip. A complete blood cell count was normal; NSAIDs were prescribed to manage the pain. The patient was advised to seek medical care if the pain increased or if local swelling or induration, fever, or general malaise developed.
In patients with a history of injection drug use, maintain a high index of suspicion for other potential health risks, such as:
• HIV disease.
• Hepatitis B and C.
• Bacteremia, with or without endocarditis.
• Local infections.
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Case 3: Multiple Papules and Scars
JOE R. MONROE, PA, MPAS
Dawkins Dermatology, Oklahoma City, Oklahoma
A 43-year-old woman presents with excoriated papules and scarring on the arms and back. All of the lesions are very similar in size and shape, and they are located on areas that the patient can easily reach.
What are your thoughts about the cause of these lesions?
(Answer and discussion on next page)
ANSWER—Case 3: Neurotic excoriations
Lesions confined to areas that the patient can easily reach strongly suggest neurotic excoriations. The presence of multiple old scars is a clue to the chronicity of this condition (A). Because neurotic excoriations are caused by the patient’s fingernails, they have a uniform disciform size and shape (B); this helps distinguish the wounds from factitial excoriations, which are made with foreign objects, such as fingernail files, forks, or other sharp implements.
A factitial disorder was diagnosed in another patient, a 30-year-old woman who used amphetamines and had an extensive psychiatric history (C). Generally, these patients have fewer lesions, which vary in size and shape.
The severity of the patient’s mental disturbance is another feature that can differentiate neurotic and factitial disease. Neurotic excoriation is usually associated with anxiety, depression, or obsessive-compulsive disorder, whereas factitial excoriation generally occurs in the setting of more serious mental illness, such as psychoses or personality disorders.
The differential diagnosis of these self-induced conditions includes scarring dermatoses such as lupus, particularly discoid lupus. Treatment options for neurotic excoriation are anxiolytic drugs or antidepressants. Usually, more potent psychotropic agents are given to patients with factitial disease.
(Next Case on Next Page)
Case 4: Hyperpigmented Areas of the Palms
ROBERT P. BLEREAU, MD
Morgan City, Louisiana
During a routine annual physical examination, a prominent area of hyperpigmentation was noted on the palms of a 7-year-old African American boy.
What steps will you take to determine the cause of this discoloration?
(Answer and discussion on next page)
ANSWER—Case 4: More in-depth history taking revealed skin grafting was the cause
Before undertaking an extensive workup to discover a perhaps exotic cause of this puzzling condition, a more in-depth history taking was warranted. In response to questioning, the child’s mother reported that the patient had suffered third-degree burns on both palms at age 2 years; skin from the thigh, which is naturally darker in color, had been used for grafts on the injured hands.