Diagnosing mysterious recurring painful blisters

Diagnosing mysterious recurring painful blisters
Diagnosing mysterious recurring painful blisters

A 48-year-old patient presented to our dermatology clinic with painful blisters on his hands that he had noticed the previous summer. The patient was new to our practice, and had already visited his primary care physician for the problem without resolution.

The patient said that the blisters had resolved over the winter, but reoccurred with a vengeance in the summer. He had been treated with topical steroids, topical antifungals and reported trying a wide variety of OTC treatments.

The patient reports feeling frustrated, as his blisters interfere with his job. Many friends have offered advice -- he might have allergies (a registered nurse) or perhaps cancer (friends). He enjoys motorcycle riding and is worried his fellow riders think he has a contagious disease.

Physical examination reveals an apparently health middle-aged man who looks his stated age. Upon examination, one notices tense multiple bullous lesions, some ruptured and some still intact. The lesions are present on both arms and hands. He has multiple tattoos on his arms. When asked, he states that when he pulls his hands out of his pocket the lesions tend to worsen.

Upon questioning he states that his urine is "maybe a little dark," and his bowel movements are "maybe a little lighter than normal." The remaining examination is unremarkable with the exception of hypertrichosis in the periorbital region and mild pink fluorescence of a urine sample.

Upon further questioning, he stated his father died of hepatitis, but he does not know what type. He denies any drug use or multiple sex partners. He states he consumes an occasional beer, defined as two beers twice a week on average.

I explained to him that I felt that his symptoms were consistent with porphyria cutanea tardae (PCT), and addressed the potential risk for hepatitis C. A biopsy was obtained, which confirmed the diagnosis. A liver function test revealed a mild elevation of liver enzymes and a total bilirubin of 2.4. A mild anemia (12 HGB) was noted with multiple morphology changes of the RBCs. Hepatitis C antibodies, viral load and phenotypes analysis confirmed the diagnosis. A ferritin level and HIV (negative) were ordered.

The patient was diagnosed with both PCT and hepatitis C. Options for PCT treatment were reviewed and a referral to a liver specialist was made in concert with his primary care physician. At his first follow-up appointment, the patient had already noted marked improvement of his lesions with physical sunblocks.

The patient told me he was shocked that I was able to make a diagnosis within 15 minutes of meeting him. I explained to him that this is just my job, it's what I do. His deep appreciation for the time I spent with him and for the prompt diagnosis reminded me why I chose this profession.

I spend a lot of time advocating for nurse practitioners on both a state and federal level. It is exhausting to hear the exaggerated stories of our clinical errors. I look back on patients that I have diagnosed with normal pressure hydrocephalus, Merkel cell carcinoma, Kawasaki disease and the list goes on.

The ability to make a difficult diagnosis is not unique to me -- I see my fellow nurse practitioner colleagues do it all the time. Most of these diagnoses are made after the patients have seen a primary care physician and on occasion after they have seen a specialist. I do notice that as a profession we tend to be fairly quiet about our abilities, and do not criticize the failure to diagnose in others.

I have great respect for the medical community and have learned much from my physician friends and colleagues. There are so many patients who need our care and so many threats to both of our practices. My deepest wish is that we could work together, but not necessarily in a statutory mandated physician led team, to achieve great outcomes for our patients.

This patient renewed my drive to have nurse practitioners recognized for who we are and the things we do to improve our patients' health. To do this well, we need to practice at the top of our license and education. In this instance, my patient benefited from my ability to do just that.

Kathleen Haycraft is a nurse practitioner from Hannibal, Missouri.

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