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Circular Erythematous Plaque at the Area of Median Sternotomy

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 60s was referred to our clinic because of a well-demarcated, circular erythematous plaque that had been present at the area of median sternotomy for 3 months. Physical examination findings revealed a 20-cm–diameter plaque that consisted of multiple concentric annular formations with raised erythematous margins and studded with numerous blisters and pustules, some coalescing into lakes of pus (Figure 1A). Nikolsky sign was not elicited, and oral, ocular, and genital mucosa involvement was absent. The patient did not report other symptoms, and findings of the overall physical examination were normal.

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C. Linear IgA dermatosis

A biopsy specimen showed a subepidermal bulla, prominent neutrophilic infiltrate arranged in a linear fashion, and evidence of dermal papillary microabscesses. Direct immunofluorescence (DIF) study results demonstrated linear deposits of IgA along the basement membrane without C3, IgG, or IgM antibody deposition (Figure 2). The diagnosis of linear IgA dermatosis (LAD) was rendered on the basis of clinical, histologic, and DIF findings.

Prior to the patient’s clinical admission, the lesion was treated as a surgical wound infection, and the patient was sequentially prescribed amoxicillin and clavulanic acid, doxycycline, ciprofloxacin and clindamycin, and fluconazole as an add-on therapy, with minimal clinical response. After confirmation of the diagnosis, the furosemide and amiloride were discontinued and replaced by hydrochlorothiazide and valsartan. He started a regimen of dapsone and achieved a short clinical improvement followed by important clinical deterioration.

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Article Information

Corresponding Author: Georgia Kyriakou, MD, MSc, Department of Dermatology, University General Hospital of Patras, Patras, PO Box 265 04, Greece (geo_kyr@yahoo.gr).

Published Online: December 11, 2019. doi:10.1001/jamadermatol.2019.3883

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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