The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
A 50-year-old woman who lives in South Carolina developed a pruritic migratory eruption that has recurred multiple times over the past 4 weeks (Figure 1). Similar lesions are noted on the trunk and proximal extremities. Her primary care physician noted mild peripheral eosinophilia and past positivity for antimicrosomal antibodies. The doctor prescribed a betamethasone-clotrimazole cream that has been of little benefit.
She thoroughly describes how much the itch affects her daily functioning and provides an hour-by-hour account of the locations of the lesions, how they moved from one spot to another, and how little sleep she is getting.
The patient has two cats and a dog, but they have not experienced lesions or other symptoms. She recently traveled to Colorado, where she hiked and drank water from local streams. She does not recall experiencing watery diarrhea but has a long history of irritable bowel syndrome (IBS) and intermittent bouts of loose stools. She says she is allergic to peanuts and birch pollen but has no current respiratory symptoms.
Of note, she has two cousins with systemic lupus erythematosus, one of whom has been treated with immunosuppressive therapy for rapidly progressive kidney disease. She is very concerned about the possibility of lupus. She also expresses concern about the possibility of Lyme disease , given her outdoor activities and history of hiking. She notes that she has traveled in the past to parts of the Midwest and New England (areas known for this condition) and recalls removing a few nonengorged ticks after hiking. She wants to know how to protect herself in the future.
Her history is positive for recurrent oral herpes simplex infection and recent use of a sulfa drug and a nonsteroidal anti-inflammatory drug, as well as a preceding upper respiratory tract infection, but she reports no new medications.
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Cite this: Dirk M. Elston. An Anxious Hiker With Recurring Annular Rash and Sleep Loss - Medscape - Jan 26, 2022.