(BMJ)—A woman in her 40s presented with a vesicular, painful, itchy rash on the tips of her fingers 1 week after a manicure. Review of sx: fatigue, fever, HA, joint stiffness. Exam: periungual erythema, edema, subungual hyperkeratosis, petechiae of finger and thumb tips, with paronychia on 1 finger. What’s the dx?
Pseudomonas aeruginosa infection
Nail psoriasis
Contact dermatitis
Herpes simplex infection
Tinea unguium
You are correct. Punch bx was consistent with a dx of allergic contact dermatitis. The gel nail polish contained acrylate. Although acrylate-induced contact dermatitis is common, systemic sx associated with contact dermatitis are rare (4.8%). Manicures involving acrylate containing nail polish should be considered as a cause of periungual contact dermatitis and potentially systemic sx. The patient’s sx resolved shortly after removal of the nail polish by soaking in acetone for 15 minutes.

BMJ 2021;375:e067253
(BMJ)—A 3-year-old girl presented with a 10-month hx of recurrent multiple painful ulcerative lesions. She had no response to antibiotics. No systemic, GI, or arthritic sx. Exam: ulcer on face, with purulent discharge. Labs: elevated WBCs, decreased Hgb. Bx showed numerous neutrophils in dermis. What’s the dx?
Cutaneous squamous cell carcinoma
Bacillary angiomatosis
Pyoderma gangrenosum
Tuberculosis
Impetigo
You are correct. The patient was diagnosed with pyoderma gangrenosum (PG) according to the Delphi consensus criteria. She met the major criterion—bx of the ulcer edge demonstrating neutrophilic infiltrate—and 3 minor criteria: exclusion of infection, multiple recurrent painful ulcerations, and decreased ulcer size within 1 month of corticosteroid tx.

Pediatric PG is easily overlooked and misdiagnosed due to its infrequent incidence and atypical areas of involvement, such as the head or face. Prompt dx and tx are essential to avoid severe scar healing and negative aesthetic and mental health effects. Notably, systemic comorbidities, such as inflammatory bowel disease, occur in ~50% of PG cases, including children.

This patient’s lesion and WBC count improved after 4 weeks of tx with methylprednisolone 1.5 mg/kg/day.

Archives of Disease in Childhood 2021;106:1001
(BMJ)—A man in his 70s presented with L eyelid ptosis. Exam: On lid eversion, a yellow, waxy lesion was seen on the palpebral conjunctiva. Labs, ECG, and echo WNL. What’s the dx?
Age-related lid involution
Pyogenic granuloma
Conjunctival amyloidosis
Lymphoma
Sebaceous cell carcinoma
You are correct. Histology showed staining of amorphous material with Congo red that displayed apple green birefringence, suggesting amyloid light chain amyloidosis. Further mass spectrometry–based proteomic analysis confirmed this finding. Systemic investigations excluded systemic amyloidosis.

Ophthalmic manifestation of amyloidosis, the abnormal deposition of amyloid protein, is rare. Clinical presentations include palpable mass, ptosis, and pain. Lid eversion is an important part of the exam in patients presenting with these sx as delayed dx can lead to increased morbidity and mortality in patients with systemic amyloidosis.

BMJ 2021;375:n2089