A  Doctor in his entire Life treats thousands of patients during the course of his medical practice. But there are certain interesting cases amidst these, which prove to be significant in sharpening the diagnostic skills & have a special place in the Clinical Memory of the Doctor.
Monu Sharma’s rare psychocutaneous disease was one such interesting case.

Monu Sharma was a 16 yr old guy who worked as delivery boy at Bestie Cafe. Monu used to work hard, day & night, while sending part of his earnings to his parents living in Jalandhar.

Presentation of the Case:
It was just another day when Monu presented to our Dermatology OPD. He complained of purplish rashes which had suddenly started appearing on his forearm since last night. He also complained of burning pain along with intermittent pruritus over the rashes. I enquired with Monu for the onset, duration & progress of the lesions at which Monu replied, that he had similar lesions in previous week too, which were only two in number. However, since last night, many lesions had cropped up, which prompted him to visit us for the treatment. There was no history of fever, cough, change in bowel habit, weight loss, epistaxis, hematuria or any other bleeding manifestations. For senior opinion, I got Monu examined by our HOD too, who after inspecting the lesions, further asked Monu if he was taking certain medications or if he suffered from any systemic illnesses in recent past. He also enquired if there was any infestation of his room or bedding area with insects. Monu denied any history w.r.t all the above questions.

The general examination and the vital parameters of Monu were within the normal physiological limits. There was no pallor, oedema, icterus, clubbing, or lymphadenopathy. On local examination, we found coarse, linear, purpuric streaks over both his forearms which were bilaterally symmetrical, discontinuous, rectangular & palpable. No other cutaneous, oral or genital mucosal abnormalities were observed.

To begin with, PURPURA, in itself, is a Pandora’s box posing a great challenge to any Dermatologist’s diagnostic acumen, given the wide array of differential diagnoses it involves. From a simple trivial blunt trauma to something extreme like an autoimmune syndrome or malignancy/cancer, there are myriad causes which can give rise to purpuric rashes in a patient. And with such weird presentation & nonspecific limited history, we were faced with a diagnostic dilemma, let alone its clinical management.

Investigations, Workup, & Treatment :

Nevertheless, to begin with the further evaluation, Monu was sent for the preliminary blood investigations which included a [Complete Hemogram, LFT,RFT,RBS] & Viral markers [HIV, HbsAg & HCV]. In order to relieve his acute symptoms, Monu was prescribed oral antihistaminics and acetaminophen along with a basic moisturiser for local application on the lesions.

However, a very strange thing happened when Monu returned back to show his prescribed medications. Monu rolled up his shirt sleeves to expose his forearms & upper arms, and we were shocked to see what was at display. Fresh new lesions had cropped up just proximal to the previous ones, in an ascending manner. Monu told me that these new lesions had erupted while he stood in the queue at the institution’s laboratory for his turn. I was totally perplexed with this new development of purpuric rashes, esp. with the rapidity at which it had taken place i.e within 2 hrs. W