Although an extensive skin infestation might be expected to cause serious discomfort, this is not always the case. A holiday visit sparked concern among family members when they saw that their relative, a 53-year-old woman who lived alone, was unable to perform routine daily activities. They brought her to the hospital to be evaluated for generalized weakness and poor appetite. Her medical history was significant for hypertension, chronic obstructive pulmonary disease, and vascular dementia.
Assessment
On presentation, the patient was thin with temporal wasting and generally unkempt. She was arousable to voice but would quickly fall back to sleep during the examination. Her blood pressure was 114/68 mm Hg, pulse rate was 72 beats/min, respiratory rate was 14 breaths/min, and oxygen saturation was 95% on room air. Her skin appeared atrophic and was marked by diffuse ichthyosiform scale and hyperkeratotic thin papules and plaques in web spaces and the periumbilical region; some of those in the web spaces had a linear arrangement (Figure 1A and B).
When interviewed, the patient denied any pruritus and was not noted to be scratching her skin during her initial evaluation. Her fingernails and toenails were long and discolored without evidence of onychomycosis. However, evidence of oral thrush was noted. She did not have any cervical, axillary, or inguinal lymphadenopathy. The cardiac, pulmonary, and abdominal examination results were normal.
Laboratory results were as follows: sodium, 140 mmol/L; potassium, 3.3 mmol/L; chloride, 114 mmol/L; carbon dioxide, 19 mmol/L; blood urea nitrogen, elevated to 31 mg/dL; creatinine, elevated to 1.9 mg/dL, and albumin, low at 2.1 g/dL. A complete blood count measured white blood cells at 5.9 × 103 cells/mm3, hemoglobin level at 10.9 g/dL, and platelets at 312,000 platelets/μL. Her workup included human immunodeficiency antibody and antigen testing, which were positive. A CD4 count returned at 34 cells/mm3, a level consistent with a diagnosis of advanced acquired immunodeficiency syndrome.
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-Jessica Seidelman, MD, Reed M. Garza, MD, Colin M. Smith, MD, Vance G. Fowler Jr., MD, MHS
This article originally appeared in the September 2017 issue of The American Journal of Medicine.
