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Case Study

Chronic skin ulcers and respiratory irritation in a 35-year-old handyman

A 35-year-old man is seen at your family practice office near a large Midwestern city with complaints of “allergies” and sores on his hands and arms. Over the past 2 to 3 months, the patient has noticed the onset of “runny nose,” “sinus drainage,” dry cough, and occasional nosebleeds (both nares intermittently). There is no prior history of allergies. He has also had occasional nausea and is concerned because the sores and minor skin cuts on his hands do not seem to heal. The patient denies having fever, chills, dyspnea, or change in bowel or bladder habits, and he has not noticed excessive thirst or easy bruising. He recently began experiencing loss of appetite and weight loss without dieting.

With the exception of the complaints mentioned, review of systems is otherwise unremarkable. The patient has used various over-the-counter remedies for his respiratory problems without relief. He did, however, note significant improvement in symptoms when he visited his sister in Chicago for 5 weeks at the end of summer.

Medical history reveals only usual childhood diseases. Other than OTC decongestants, he is taking no medications. He denies use of illicit drugs, but admits to occasional social use of alcohol. For the last 16 years he has smoked 1 pack of low-tar cigarettes a day.

The patient has been employed as a mathematics teacher for 13 years; summers are usually spent in self-employment as a handyman. His hobbies include reading and tennis. Two years ago he moved into a ranch-style house located several hundred yards from a small manufacturing plant; a small pond intervenes. The home has central air conditioning and gas heat; it is supplied with well water and uses a septic sewage system. Four months ago the patient began digging up the sewage system to make repairs. It was shortly after he began digging that he first noticed the sores on his hands and forearms.

Physical examination reveals an alert white male with skin lesions on the exposed areas of the forearms and hands; edema of the hands is present. The dermal lesions include dermatitis and small circular areas with shallow ulcerated centers. ENT examination is unremarkable, and chest examination reveals a few scattered rhonchi that clear with coughing. His liver is slightly enlarged and tender to palpation. Cardiovascular, genito-urinary, rectal, and neurologic examinations are unremarkable.

Initial laboratory findings include evidence of 2+ proteinuria and hematuria, and slightly elevated bilirubin, SGOT (AST), and SGPT (ALT). Scrapings of the dermal lesions, done with potassium hydroxide (KOH) preparation, show no fungal elements or signs of infestation on microscopic examination. A nasal smear for eosinophils is within normal limits.

(a) Formulate an active problem list for this patient.


(b) What clues indicate this case may have an environmental etiology?


(c) What further information will you seek before making a diagnosis?


(d) What treatment will you recommend?


Answers to the Pretest can be found on page 19.

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