Polymyalgia rheumatica should be suspected in older patients with bilateral shoulder and hip stiffness that is worse in the morning and improves with use. An array of nonspecifi c musculoskeletal complaints, constitutional symptoms, and elevated serum infl ammatory markers may be present, so other conditions should also be considered. Prolonged glucocorticoids with patient-tailored dosing and duration are the mainstay of treatment. Corticosteroid-sparing therapy with adjunctive methotrexate may benefi t select patients. KEY POINTSRheumatoid arthritis, late-onset spondyloarthritis, and RS3PE (remitting seronegative symmetrical synovitis with pitting edema) are important mimics of polymyalgia rheumatica.Diagnosis usually requires either an elevated erythrocyte sedimentation rate (> 30 or 40 mm/h) or C-reactive protein level (> 6 mg/dL).Ultrasonographic evidence of infl ammation, especially subacromial bursitis, increases diagnostic specifi city.Patients should be evaluated at diagnosis and periodically for the development of giant cell arteritis.To help avoid relapse, therapy should continue until symptoms resolve, followed by slow tapering.Preliminary studies show possible benefi t from tocilizumab, an interleukin-6 receptor antibody, as monotherapy or for refractory cases.

The Moderna COVID‐19 vaccination was approved for use in the United States in December of 2020 1 and since that time massive public health efforts have been made to vaccinate patients against the COVID‐19 infection. Adverse reactions from the vaccination are well‐reported and include both local skin reactions, such as pain, swelling, and erythema at the injection site, as well as systemic reactions including fever, malaise, headache, muscle aches, drowsiness, nausea, and vomiting. While severe serious cutaneous adverse reactions, such as Stevens–Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN), remain rare; two cases of SJS/TEN related to COVID‐19 vaccination have been reported. We herein review the two previously reported cases of SJS/TEN and report the first case of SJS precipitated by the Moderna Inc., MRNA 1273 COVID‐19 vaccination in the United States. Although we review potential adverse reactions to vaccination, the benefits of COVID‐19 vaccination outweigh the risks based on current data. Cases should be reported to the Vaccine Adverse Event Reporting System (https://vaers.hhs.gov/) to help public health officials recognize and track these severe but rare adverse events.

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Acromegaly is a condition defined by excess growth hormone (GH). The clinical features of acromegaly including overgrowth of many tissues including cartilage, bone, skin and visceral organs. It often times presents with coarsening of facial features and increased hat or ring size. Cardiovascular disease including hypertension with left ventricular hypertrophy and metabolic deficiencies including insulin resistance are also commonly seen as a result of the GH excess. The most common cause of acromegaly has been found to be GH secreting pituitary adenomas. MRI is generally sufficient to identify these lesions, but rarely a patient with symptoms of acromegaly will be found to have empty sella syndrome. Case: A 37 year old male, with a PMH of uncontrolled HTN presented to the emergency department after his wife found him on the floor, unconscious, foaming at the mouth, and shaking. He had an episode of urinary incontinence and was postictal for 20-30 minutes after the episode. In ED, he was hypertensive at 246/162, CT head showed right frontal intraparenchymal 1.2 cm hemorrhage and MRI brain showed various foci of hyperintensity compatible with hypertensive encephalopathy. He was also hypokalemic (2.9) with evidence of an AKI (BUN 27, Cr 1.73). He was admitted for further evaluation of suspected seizure. Upon further evaluation, the patient admitted to coarsening of facial features as noted on comparison of prior photographs. He also reported difficulties with his wedding ring fitting which he attributed to hand swelling. ROS was other negative with no vision changes or headaches. This sparked concern for a secondary cause of hypertension in the setting of clinical acromegaly. MRI brain was complicated by movement but revealed pituitary characteristics of empty sella syndrome. Insulin like growth factor 1 - 745. ECHO showed severe concentric left ventricular hypertrophy with aortic valve sclerosis and left atrial dilation. Renal Artery ultrasound showed no evidence of renal artery stenosis. The patient was subsequently scheduled for repeat MRI brain pituitary as outpatient under anesthesia to evaluate for possible surgical treatment for acromegaly. Discussion: This case demonstrates that empty sella syndrome does not warrant exclusion of acromegaly. GH secreting tumors can be present despite empty sella syndrome and acromegaly can even cause enlargement of the sella (?) . In these cases, the pituitary tissue lining the sella can be the source of excess GH. Upon case review, the mechanism remains unclear but empty sella syndrome may result from necrosis by infarction or from hemorrhage. Since no resectable mass is present in these cases, medical management with somatostatin analogues remains the only treatment that can be offered to these patients. It is important to keep acromegaly on the differential despite empty sella.

Autoimmune and inherited bullous disorders are rare skin diseases that may have a profound negative impact on quality of life (QOL). Common symptoms include pain, pruritus, and scarring, and complications may result in the loss of the ability to perform daily tasks. Diagnosis may have a negative psychological impact, and ongoing management may require a significant allocation of time and resources by both patients and providers. To provide patient-centered care, consideration of these factors is of utmost importance for the dermatologist treating patients with bullous disorders. Herein, we present a review of the primary literature evaluating QOL in autoimmune and inherited bullous disorders, including pemphigus, pemphigoid, epidermolysis bullosa, and Hailey-Hailey disease.

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A 67-year-old man with long-standing hepatitis B virus and HIV managed with chronic antiretroviral therapy presented to an urgent care facility with worsening erythema and edema of the legs of 2 weeks' duration. He was prescribed a 7-day course of cephalexin for presumed cellulitis. Two months later, he developed nodules on the lower extremities. He was seen by podiatry and prescribed a course of amoxicillin-clavulanic acid for presumed infection. Despite 2 courses of antibiotics, his symptoms progressed. The nodules expanded in number and some developed ulceration. Three months into his clinical course, he presented to our dermatology clinic. Physical examination revealed two 2-to 3-cm, violaceous, exophytic, tender nodules. He reported tactile allodynia of the lower extremities and denied fever, chills, night sweats, or weight loss. He also denied exposure to infectious or chemical agents and reported no recent travel. The patient was chronically taking lisinopril/hydrochlorothiazide, escitalopram, elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, bupropion, and aspirin with no recent changes. A complete hematologic and biochemical survey largely was unremarkable. His HIV viral load was undetectable with a CD4 count greater than 400/mm 3 (reference range, 490-1436/mm 3 ). Lactate dehydrogenase was elevated at 568 IU/L (reference range, 135-225 IU/L). The lower leg lesions were biopsied for confirmatory diagnosis. WHAT'S YOUR DIAGNOSIS?a. bacillary angiomatosis b. Kaposi sarcoma c. lymphomatoid papulosis d. plasmablastic lymphoma e. plasmablastic myeloma Drs.

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