Author: Jacob Bright, DO Candidate
Co Author #1: Caitlyn Rerucha, MD Womack Army Medical Center – Family Medicine Residency Fort Bragg, NC
Co Author #2: Caitlyn Rerucha, MD Womack Army Medical Center – Family Medicine Residency Fort Bragg, NC
Co Author #3: Caitlyn Rerucha, MD Womack Army Medical Center – Family Medicine Residency Fort Bragg, NC

Patient Presentation:
A 26 y/o male soldier presented to the Emergency Department with worsening, painful, weeping plaques about dorsal feet <a href="CaseStudyImages/CS2CS1SoldierwithWid-199.jpg" title="Case Photo #2" data-lity><b>Case Photo #2</b></a> with recent progression of rash to include his trunk and upper extremities <a href="CaseStudyImages/CS4CS3CS2CS1Soldierw-199.jpg" title="Case Photo #4" data-lity><b>Case Photo #4</b></a> . He returned from a twelve-month deployment to Afghanistan six weeks prior. During the course of his deployment there was a slow worsening in dorsal foot rash with prompt worsening over several days. <br> <br>He denied any history of cold sores, oral or genital ulcers, dysuria, photophobia, or skin tenderness. He also denied ever having had any arthralgias, fevers, chills, or malaise.

History:
During the course of his deployment in Afghanistan he was treated at an aid station for tinea pedis with topical naftin (naftifine) & lamisil (terbinafine) and later oral diflucan (fluconazole) with limited improvement in his symptoms. <br> <br>Near the end of his deployment he underwent a trial of treatment for possible boot dermatitis with a <br>prednisone burst and mupirocin (bactroban). <br> <br>Past Medical History – non-contributory <br>No history of atopy, psoriasis or autoimmune disease. <br> <br>Past Surgical History - significant for a Lisfranc fracture repaired with internal titanium fixation (2008). <br> <br>Medications - previous oral medications included doxycycline and primaquine after returning from deployment with last dose six weeks prior to presentation. <br> <br>Allergies - no known history of drug or food allergies. <br> <br>---------------------------------------------------------- <br>Initial TX upon presentation to Emergency Department: <br> <br>120 mg IM methylprednisolone (Solu-medrol) prior to examination by the Family Medicine Inpatient Team / Dermatology <br> <br>Wound, viral cultures, Tzanck prep & KOH were performed. <br> <br>Broad-spectrum empiric antibiotics were initiated for coverage against both gram positive and gram negative organisms as well as possible herpetic overlay with IV Clindamycin, IV Zosyn & IV Acyclovir. <br> <br>He ultimately was transitioned to oral antibiotics (levaquin, clindamycin) and oral valtrex (valacyclovir) as his clinical picture improved during the hospital course.

Physical Exam:
General Appearance: <br>AAOx3 – appeared uncomfortable but non-toxic and in no acute distress <br> <br>General Medical Exam: <br>HEENT, cardiovascular system, pulmonary system and abdominal exam – unremarkable <br> <br>Exam unchanged throughout hospital course <br> <br>Full Body Skin Exam (at presentation): <br>Well-demarcated, symmetric involvement of dorsal feet <a href="CaseStudyImages/CS2CS1SoldierwithWid-199.jpg" title="Case Photo #2" data-lity><b>Case Photo #2</b></a> : <br>Brightly erythematous, macerated plaques with discrete and confluent overlying erosions. There were several areas ‘punched out’ in appearance and clear, honey-colored crusting was present. <a href="CaseStudyImages/CS5CS4CS3CS2CS1Soldi-199.jpg" title="Case Photo #5" data-lity><b>Case Photo #5</b></a> <br> <br>Web-spaces of feet: <br>Maceration, deep-seated vesicles, honey-colored crusting. The plantar surfaces were never involved. <br> <br>Hands: <br>Numerous tense-walled deep seated papules, papulovesicules about dorsal and lateral surfaces of fingers <a href="CaseStudyImages/CS6CS5CS4CS3CS2CS1So-199.jpg" title="Case Photo #6" data-lity><b>Case Photo #6</b></a> . <br> <br>Trunk: <br>Discrete and confluent erythematous papules and plaques. Some of these also had mild overlying scaling <br> <br> <br>Pertinent negatives from full body skin exam: <br>There was never any mucosal involvement or skin tenderness/erosions (aside from feet). There were no stigmata to suggest psoriasis at time of initial presentation, to include examination of: scalp, extensor surfaces (elbow/knees), and nails, groin & buttocks.

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