One of My Toughest Cases
Story by Victoria Perkins, New Orleans Magazine
The man whose body turned red
PHOTOGRAPHED BY SARA ESSEX
Dr. Erin Boh frequently sees patients with debilitating skin diseases. Generally, the case is a straightforward incidence of eczema, psoriasis or any number of cutaneous diseases. However, sometimes a patient walks in with a rash that's a complete mystery.
One such case was a 62-year-old man who seemed to be in perfectly good health other than presenting with a red rash over his entire body. After being passed from one stumped dermatologist to the next, the man ended up in Boh's office.
"He developed what we call erythroderma, which is basically the 'red man' syndrome. He presented, over the course of about a month or two, with total body redness, and as a consequence of that his skin started to peel off."
According to Boh, "red man" syndrome is like the worst sunburn imaginable, complete with peeling and itching. The patient was experiencing all of that along with losing fluid through his painfully swollen skin. The loss of fluid eventually led to his heart beating faster and working harder until finally his kidneys started to fail, meaning his skin rash had left him almost completely incapacitated.
Boh suspects that other dermatologists simply hadn't listened to the patient, and they were quite literally only looking skin-deep for the source of his problem. "They sort of looked at the skin and thought they could treat it with topicals and this-or-that. They didn't know what was causing it, but they didn't even listen to him. So, he's in my office and he's sitting there and he's miserable. His hands are swollen, his feet are swollen, he can't put on shoes, his pants are kind of wet because he's got oozey, dripping fluid from all over and he's very, very miserable.
His joints are so swollen that he can't put on a shirt; his wife has to dress him. So, here's this 60-something-year-old man who's been the pillar of strength his whole life, taking care of the family, the kids and he can't go to the bathroom without help because he's so devastated and crippled and swollen."
Boh looks at skin the way a tourist looks at a map of the French Quarter – as if it holds some rare, precious knowledge. According to Boh the skin can be an incredible tool in uncovering a patient's particular ailment, and in medical dermatology it isn't rare to see cases where the skin gives some clue to what's going on inside of a patient.
Years of experience have taught Boh that the best way to get to the heart of the matter is to simply listen to the patient; not only the words they are speaking, but also the internal cues a persistent doctor can pick up on. "Of course, then, the first thing we do is listen to him and hear that he has an irregular heart beat, so we recognize that what tripped him into this state of erthyroderma was his irregular heart beat." She discovered the man was experiencing a vicious cycle of symptoms: an irregular heartbeat causing a horrible skin rash, a rash causing blood loss and blood loss causing an even more distressed heart.
Figuring out the internal problem wasn't the end, though, as Boh still needed to understand how the whole attack had started. "Was his skin red all over because he had lymphoma? Or was it because he just had psoriasis, which was out of control because his heart wasn't pumping right?" In order to understand exactly what was going on with the patient, she ordered a spate of biopsies and blood tests and consulted with a cardiologist. "We were able to find out from our biopsies and our blood work that the patient indeed had psoriasis. He had had an irregular heart beat which, not uncommonly, is associated with psoriasis and that irregular heartbeat had then finally made his psoriasis so bad, without causing him symptoms of his heart, that he then went to the doctor because he was red all over."
Armed with the proper diagnosis, Boh determined the best course of treatment. "We were able, by working with the cardiologist, to put him on medicines by mouth and then subsequently an infusion. His skin and joints went totally back to normal, he was able to get put on medications for his heart and get his heart treated, and so now, years later, he continues with this infusion. And all of that came about not because he was symptomatic with his heart but it was because his skin manifested negatively to what was going on internally."
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