November 2004

You may have noticed that I am frequently introducing guest columnists. I have plenty of clinical material, but I find it particularly rewarding to hear from others who have seen and photographed noteworthy cases. If you would like to be a guest columnist, and you have a good case with publishable pictures, please let me know by writing me at jhbrien@aol.com. Prints or slides are best, but digital pictures with good resolution may be used. The scanned photo should have a minimum of 300 DPI. You also need to have permission to publish the picture, especially if the face is to be shown.

My guest columnist for this month, and also for the December issue, is Josué Molina, MD. Dr. Molina is a graduate of the medical school in Monterey, Mexico: a very fine medical school that I had the opportunity to tour on a recent trip there for Grand Rounds with Enrique Mendoza, MD. Dr. Molina began his pediatric training in Mexico City and then came to Scott & White to complete his pediatric residency in 1997. He has been in practice in Del Rio, Texas, since then, at the United Medical Center, a nonprofit organization that operates using government grants to see the uninsured and underinsured. Dr. Molina also sees pediatric patients at Laughlin Air Force Base. His description of the services available sounds fairly austere, with some limited subspecialty support from San Antonio. As difficult as it may seem to be at times, Dr. Molina has kept his interest in the academics of pediatrics, as illustrated in the cases that follow below and next month.

Case

A 2½-year-old healthy girl was brought to the outpatient clinic with the chief complaint of “spots” on her back that were noticed four days before. There was no known injury or illness to explain them. However, her mother reported the child having a brief, nonspecific febrile illness two weeks before the onset of this problem. Her past medical history is otherwise unremarkable. Her mother denied the use of any topical medications other than sunblock that was used frequently during the summer, as the patient likes to frequently play in the family pool. Otherwise, her skin was not known to be exposed to any other products. The mother denied knowledge of any physical abuse.

Social history: The patient is an only child, and her parents are not married. The child lives with her grandparents. Her mother, who lives 450 miles away, happened to be visiting at the time of the clinic visit. The patient’s father was also present, but had just been released from jail, where he served time for domestic violence.

The child’s immunizations were up to date.

Examination revealed a very anxious and uncooperative child with normal vital signs. She was well groomed and appeared well nourished. Her height, weight and head circumference were growing along the 5th percentile and her development is appropriate for her age. On inspection of her skin, there were several dark brown to maroon, painless macules on her upper and lower back that appeared to be in the general shape of fingers (Figures 1-4). There were no blisters or excoriations. There was no surrounding erythema, swelling or warmth to the touch.

The rest of her exam was normal.

Due to the uncertain nature of the lesions and the disruptive social situation, Child Protective Services (CPS) were notified. The patient was seen daily for the next four days, and then a week and three weeks later, during which time minimal change to the color of the macules was seen, although they did become lighter. At this time, she was also seen by a dermatologist for opinion. The spots were totally gone two months later, and the child remained well.

What’s Your Diagnosis?

1. Bruising from nonaccidental trauma
2. Urticaria pigmentosa
3. Berloque dermatitis
4. Nummular eczema

Answer

The dermatology consultant diagnosed the child with berloque dermatitis (C). The word “berloque” is a French word meaning trinket, as in jewelry. According to Ai-Lean Chew, MBChB, a research fellow in the department of dermatology at the University of California, San Francisco, who writes in e-medicine, the term was coined by O. Rosenthal in the German dermatology literature in 1925. Chew also points out that Freud described a similar condition in 1916, attributing the marks to sun-exposed areas that had eau de cologne applied. This typically occurred on the neck in a necklace-like distribution, therefore the reference to jewelry. It has since been found to be due to a photoactive ingredient in bergamot oil, an extract from the bergamot lime that is used in many topical products for its fragrance, such as soaps, colognes and sunscreens.

When bergamot oil is applied in high concentrations and then exposed to the sun, this combination stimulates melanogenesis, increasing the number of melanocytes. Initially, there will be itchy erythema, followed by the hyperpigmentation seen in the figures, which may initially be misdiagnosed as bruises, eczema or urticaria pigmentosa. These hyperpigmented macules may persist from months to years, and some may be permanent. As noted above, the spots on the patient faded significantly in two months. Presumably, the lesions were caused by an ingredient in the sunscreen lotion that she had been using, or possibly something left on the mother’s fingers as the child was picked up prior to going out into the sun. It is likely that it was a product not obtained in this country, as there are regulations governing the amount of bergamot oil a topical can contain.

Other choices

Urticaria pigmentosa is a form of mastocytosis, which is marked by an increased concentration of mast cells in various tissues, usually the skin. These lesions, seen in Figure 5, may appear from infancy on, and will become urticarial with anything that causes degranulation. Usually this is a result of minor injury or topical stimulation as shown in Figures 6 and 7, using a tongue blade to rub a lesion with resulting wheal and flare (erythema). For those of you who keep these columns, I published the case of urticaria pigmentosa shown here in the June 2001 issue of this newspaper.

Nummular eczema (Figure 8) was actually featured in last month’s issue of this newspaper. So, if you guessed D, you apparently did not read the last issue, or like me, you are starting to have short-term memory loss. Nummular eczema can occur at any age and is, by definition, an annular patch of dry, inflamed skin. Nummularis is a Latin word meaning “coin-shaped” and eczema is a Greek word meaning “to boil out.” The lesions tend to occur on the extensor surfaces of the extremities, shoulders, buttocks and lower trunk and often occur in a symmetric distribution. They are usually very pruritic, and as a result, lichenification and secondary infections are common due to chronic scratching.

The possibility of nonaccidental trauma should always be considered in a child with unexplainable skin lesions or marks that resemble bruising. Pending definitive diagnosis, social services should be notified, as was done in this case, especially in a chaotic social environment. Parents with nothing to hide are usually very cooperative, as were these parents, and want to get it resolved as soon as possible. If it is determined that the marks are bruises, especially in an area of the body without bony prominences, like the abdomen, thigh or back, as shown in Figure 9, and the history does not fit, then child protective services will take over the disposition of the child. That is, of course, if there are enough caseworkers to go around in this badly understaffed and underfunded agency.

None of the conditions mentioned above is an infectious disease, but we need a curveball every now and then to keep everyone on their toes.

Columnist comments

On Sept. 23, at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., the First Annual James W. Bass, MD, Visiting Professorship was held. The first visiting professor was Errol Alden, MD, (Figure 10), the executive director of the AAP. Dr. Alden reported on the state of pediatrics in the United States and tied it in with that of the military services. Dr. Alden is, like his AAP predecessor, Joe Sanders, MD, uniquely qualified to discuss the state of pediatrics in this country from both the civilian and military perspectives, as he is a retired colonel in the U.S. Army Medical Corps also. Jim Bass (Figure 11, courtesy of John Pierce, MD), who died in 2001, was eulogized in this column by me in the August 2001 issue. As noted then, Bass was the founding chairman of pediatrics at the USUHS, F. Edward Hébert School of Medicine in 1976, with an entering class of 32 students. Since then, this medical school has grown into one of the most competitive in the country, turning out career-oriented physicians in all branches of the military and the Public Health Corps. When these physicians separate from the uniformed services, they join the civilian community as outstanding contributors in their medical field.

I was honored to be allowed to play a small role in this event by introducing the Jim Bass story to those in attendance. The James W. Bass Visiting Professorship will rotate around the various services and military medical centers in the fall of each year. It is undecided at this point where it will be held next year, but for more information, I would recommend going to the USUHS Web site. For those of you interested in contributing to the funding of this professorship, especially those of you who trained under Bass, your tax-deductible donations can be made to the Henry M. Jackson Foundation, J.W. Bass Fund #101259. I will pass on any information regarding the next Bass Visiting Professorship as soon as I have it.

I would like to thank Dr. Molina for contributing this unusual case. He also provides another equally interesting case for next month. By the way, Dr. Molina’s home of Del Rio, Texas, became famous in the early 1960s when a young Wolfman Jack was hitting it big as a radio personality by broadcasting rock and roll music out of XERF-AM in Cuidad Acuna, Mexico, just over the border from Del Rio. This radio station was about five times as powerful as radio stations in the United States, but legal in Mexico. So, the Wolfman could be heard virtually throughout North America, and many of us who were growing up in the ’60s were regular listeners. The movie “American Graffiti” gave a glimpse of the teenage world and their music of the ’50s and ’60s, and how it related to the Wolfman as he was portrayed as himself in the movie.

I wish you all and all our military personnel overseas a very joyful Thanksgiving. — James H. Brien, DO

For more information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White’s Children’s Health Center and Associate Professor of Pediatrics, Texas A&M University, College of Medicine, Temple, Texas; and Josué Molina, MD, general pediatrician practicing in Del Rio, Texas, and Laughlin Air Force Base.