IntroductionChilblains or perniosis is an acrally located cutaneous eruption that occurs with exposure to cold. Chilblains can be classified into primary and secondary forms. The primary or idiopathic form is not associated with an underlying disease and is clinically indistinguishable from the secondary form. The secondary form is associated with an underlying condition such as connective tissue disease, monoclonal gammopathy, cryoglobulinemia, or chronic myelomonocytic leukemia. Histopathology cannot accurately help distinguish the primary from secondary forms of chilblains. This article will raise the awareness of chilblains by presenting two unusual case reports of chilblains in men from Southern California with discussion of the appropriate evaluation and treatment of this condition.Case presentationsCase 1A 56-year-old Caucasian man presented in January to a Southern California primary care clinic with a report of tingling and burning in both feet, followed by bluish discoloration and swelling as well as blistering. He had no unusual cold exposure prior to the onset of his symptoms. He had a history of “white attacks” in his hands consistent with Raynaud’s phenomenon. His symptoms gradually resolved over a 3-week period.Case 2A 53-year-old Caucasian man also presented to a Southern California clinic in January with a 3-week history of painful tingling in his toes, and subsequent purplish-black discoloration of the toes in both feet. His symptoms occurred 1 week after a skiing trip. He had partial improvement with warming measures. His symptoms resolved 2 weeks after his initial presentation.ConclusionsChilblains is a relatively uncommon entity in warmer climates but can present during the winter months. Primary care providers in warmer climates such as Southern California in the USA may be unfamiliar with its presentation. It can be diagnosed clinically by the appearance of typical lesions during the cold damp season. Through a thorough history, physical examination and selected laboratory evaluation, underlying connective tissue disease or a mimic such as vasculitis or cutaneous leukemia can be excluded.
OSTEITIS DEFORMANS.MEDICJBRA more time to the soft tissues where the pain appears to be, (comparing if necessary with the other side, we may note somie resistance in a part of the muscle, and the patient will tell us we are exactly on the offending spot; on continuing the examination we may presently discover that the resistance is due to a definite fibrous thickening. Further useful information illay be obtained by.working from the patient's point of view. Wlhen we palpate the tissues and try to define the indurations, we are carrying out the ideal massace for this condition, and tlle sufferer will know at once that to coutinuo tlhose manipulations would do good. In this we have tlhe key to the treatment-inamely, massage, which is not merely superficial rubbing, but is really a repetition of the manipulations carried out during our examination. Changes can acfually be felt to take place in the fibrous tissue under the influence of massage. The foregoing is typical of tlle easily recognized condition of fibrositis as seen in muscular rheumatism; more obscure cases may be due to minor degrees of fibrositis wlhich may be difficult to diagnose. Time and patience are necessary, but frank co-operation witlh tlle patient will tell us if As the examination proceeded the tissues soon relaxed sufficienitly to allow certain definite painful fibrous strands to be felt.My mind was now fully made up that here was a case of fibrositis with every reasonable prospect of clearing up. The treatment, which consisted of massage and diathernmy, was attended by improvement, and1 after thirteen visits the patient was quite free from pain. There has been no return of aniy discomfort since she was last seen over twelve months ago.It will be observed that we may easily be misled unless we keep before us -the possibility of fibrositis. A person with pain in tho left side of the chest may have a systolic murmur at the apex, yet tlle origin of his complaint be entirely in the intercostal muscles. Similarly, -people may lhave pain in tlhe loins arising from the muscles in the back and quite unconnected with tlhe kidneys, even thouglh the urine miglht show a trace of albumin. In the case just quoted the anal fissure was not to blame, yet lhad some pelvic disorder been present our minds would have turned to that as the causative agent.In certain otler conditions the cause may be found in a region unsuspected by the patient. Heada^he is often due to indurations in the upper fibres of the trapezius, and relief quickly follows appropriate treatment of these areas. In several cases of flatulent dyspepsia tlle condition hag been speedily cured by treatmuent directed to fibrous nodules or strands in the erector spinae muscles.In one instance a lady who for several months had had headache anld sickness, with actual vomiting after dinner, was seen one afternoon during an attack of headache; this disappeared after about ten 'minutes' massage to the back of the neck, and there was no sickness that evening-the first time for months. Further examination...
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