A Man With Skin Plaques Has Severe Pain After Eating

Stephen Suah, MD, MS; Padma Chitnavis, MD; Mary Maiberger, MD


September 25, 2020

Physical Examination and Workup

Upon physical examination, the patient is a well-nourished and well-appearing elderly man in mild distress. His temperature is 99°F (37.2°C), respiratory rate is 18 breaths/min, heart rate is 90 beats/min, and blood pressure is 130/70 mm Hg. No facial abnormalities are noted. Extraocular movements are intact. No oral mucosal abnormalities are noted. No jugular venous distention is observed.

Auscultation of the lungs reveals clear breath sounds bilaterally. Cardiovascular examination reveals normal sinus rhythm and an absence of murmurs. Auscultation of the abdomen reveals normal bowel sounds. Palpation of the abdomen does not reveal tenderness, guarding, or rebound pain.

Visual examination of the abdomen reveals multiple faint, yet discrete, erythematous plaques in both upper quadrants. In addition, there are scattered crops of solitary and grouped, pink vesicles in linear and geometric configurations on the mid- and lower back extending across to the torso. Similar-appearing vesicles and a crusted, hemorrhagic plaque are noted on the right popliteal fossa (Figure 1), for a total of > 25 vesicles.

Figure 1.

Laboratory and imaging are significant for the following findings:

  • Total leukocyte count, hemoglobin level, hematocrit level, platelet count, and serum creatinine level: normal

  • Aspartate aminotransferase level: 330 IU/mL

  • Alanine aminotransferase level: 408 IU/L

  • Serum bilirubin, alkaline phosphatase, and amylase levels: normal

  • Hepatitis B surface antigen and antibodies to hepatitis A, C, and E viruses: negative

  • Autoimmune markers for liver disease (antinuclear antibodies, anti–smooth-muscle antibodies, and anti-liver kidney microsomal antibodies): negative

Ultrasound of the abdomen does not demonstrate any gallstones or any feature suggestive of underlying liver disease. Contrast-enhanced CT of the abdomen reveals a normal pancreas.


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