Case 19: A Hot Mess

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The nurse at triage can feel her heart race as Madison raises her shirt and shows the splotches around her thin waist. She calls another nurse over, quietly, hiding the worry that’s taking her breath. She wants to put Madison in a monitored bed, but her gut tells her to wait – that she looks too well. “Are you sure you’re feeling okay?” the nurse asks, searching for signs of illness, as she reels off a list of symptoms.

“On and off,” Madison says, when the nurse mentions ‘light-headedness,’ but other than that, she says she feels fine.

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It was Madison’s friend, a new nursing graduate, who’d told her to get it checked out as soon as possible. She’d seen the same rash on a patient in Intensive Care. The rash, she was told, is a harbinger of death – a sign that the body is beginning to shut down. The nurses check Madison’s blood pressure. It’s normal, as are the rest of her vital signs – her pulse, her temperature, and her oxygen saturation. She can’t be that sick, the nurse decides, assigning her to an ambulatory area. She’s young, she’s smiling, she’s animated, she’s vibrant. Just to be sure, though, the nurse walks her over to me, chart in hand, and furrows her brow. “It’s strange,” she says, describing the rash. “She seems fine, but it looks like the real thing.”

Madison is twenty-two. She’s recently finished her undergraduate degree in Sociology and has begun looking for work. She has no medical problems, has never had surgery, and doesn’t take any medication. She doesn’t smoke, doesn’t use street drugs, and drinks on weekends. Dark-haired, green-eyed, and fitness-model fit, I’ve already decided she can’t be that sick – before I’ve examined her, before I’ve even looked at her rash.

Her trouble started weeks earlier, with intermittent abdominal pain. It often worsened with food, and was accompanied by bloating, and constipation, which at times, were debilitating. There was no vomiting, and no significant weight loss, although at times, she was afraid to eat. I examine her. Her head and neck are normal, as are her lung and heart sounds. I ask her to lie down and she raises her t-shirt. The rash is dramatic – a burgundy web, with pale splotches. It does look like mottling – a common clinical sign of shock, due to lack of blood flow to the body’s tissues. I palpate her abdomen. The rash is not raised, and she is non-tender. I listen. Her bowel sounds are normal. I can’t even think of what test to order to help me figure it out.

About a year ago, a colleague told me that he was going to see someone at a well-known supplier of foot-appliances. “They actually have a medical director there who’s supposed to be pretty good. ” I said the name before he did – Morty Silverberg* – shocked that he was still working. Eighteen years earlier, when Dr. Silverberg seemed to be in his fifties (he likely always seemed in his fifties, even as a child), I spent a month with him during a Geriatrics rotation. I hated it. The problem, I’d complain to my girlfriend, was that I was learning to be a doctor, not a shoe salesman. Twice a week, I’d meet him at his storefront, while he assessed the elderly, and helped them mobilize.

What I didn’t realize, like the 1980s Karate-Kid who was unwittingly learning a martial art by waxing cars, was that I was absorbing more in that shoe store than I was in the classroom. He knew the Latin term for every medical condition – so many terms that he could break them apart and converse with the ancient Romans. He told me to read about medicine for one hour each day, for the rest of my life, if I wanted to be a successful physician (I hope writing counts). And every day, he’d point out subtle findings on physical exam that most clinicians would miss.

“I’m re-training in musculo-skeletal medicine,” he said one morning in his monotonous drawl. “I did the same with Dermatology a few years ago.”

“Do you have any interests outside of medicine?” I asked.

“Photography,” he said.

“Really? What do you photograph?”

“I just told you,” he said flatly. “Dermatology. I have over ten thousand photographs of skin rashes.”

One afternoon, he showed me splotches on the abdomen of an emaciated eighty year old with colon cancer, his clothes so oversized, they looked like they belonged to someone else. He snapped his fingers and pointed. “What is this rash,” he asked me.

“No idea,” I said.

As I’m thinking of how to proceed with Madison, I remember the rash, and the latin name that goes with it. “Do you use a hot water bottle?” I ask her.

“A heating pad,” she says. “Every night.”

“That’s not mottling,” I say. “That’s a burn. Erythema Ab Igne. Redness from fire. Stop using the heating pad and it will go away.” Erythema Ab Igne, or ‘toasted skin syndrome’ is caused by skin absorption of infrared radiation. Madison was lucky, and although it took weeks, the rash slowly faded, then disappeared. Prolonged exposure, however, can cause permanent skin changes, which carries the risk of transformation to skin cancer. Recently, there has been an increase in the incidence of Erythema Ab Igne of the thighs, due to the use of laptop computers. Madison’s abdominal pain, bloating, and constipation also settled, after she moved back home after four years away at school, and made changes to her diet.

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*Morty Silverberg is not his real name (but it’s pretty damn close)

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