A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.
Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.
The pathologist called, sounding perplexed. "Was he … around any cacti?"
Drat! I always forget to ask patients whether they've cuddled any cacti.
When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…
Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.
In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.
Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.
Here are a few examples from my own collection:
▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.
Hot-tub folliculitis? No whirlpool baths in the park.
Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?
I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.
▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.
A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.
It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.
Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.
Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.
He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.
▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.
"Have you," I ask, looking mysterious, "had any margaritas lately?"
"Why, yes!" they reply, startled. "In Cancun."
"Where you had your drink in a lounge chair, right?"
They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.
▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.
Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.
Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.
Other vacationers show up with cnidarian tales.
Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.
What counts as exotic depends, of course, on where you live.
Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.
"Do you think we'll get to see poison ivy?" she asked.
I told her we might indeed.