Dermatology (Guest Contributions Edition)

Dear friends,

It gives me great pleasure to present a very special "Guest Contributions Edition" of the Historical Grand Rounds. There is no higher mark of friendship than lending time and enthusiasm to another's interests, and I'd like to sincerely thank those who took part. I hope you find each other's cases as interesting and inspiring as I did.

1. George Washington, by Jason

We start at the beginning. Our beloved American patriarch, George Washington, is best known as the first United States President, the president of Constitutional Convention in 1787, and the commander-in-chief of the Continental Army during the American Revolution. Unfortunately, all of the time he spent outdoors fighting the British would have made for a dermatologist’s nightmare, especially given Washington’s pale complexion. Check out the following portrait by William Joseph Williams for the Alexandria Masonic Lodge number 22. The portrait was completed in 1794, during Washington’s second term as President. Do you notice anything on his right cheek? How about next to his right ear?



Fortunately, Washington had access to the best medical care 18th Century America had to offer. Washington wrote a testimonial letter on behalf of Dr. James Tate on February 25, 1795 in which he might have been referring to this lesion:“I have, myself, experienced the fruits of his skill, in this art; being cured by him of an irritable spot on my right cheek which had for years been increasing in pricking and disagreeable sensations; and in June last assumed the decided character of a Cancer; of which I was perfectly relieved by Doctor. Tate in about two months by an easy course, under the operation of which I felt no confinement, or other inconvenience at that time, nor any injury to my constitution since.” Further sources indicate that Washington was treated with the repeated application of a cream or paste. Based on these clues, what is the most likely diagnosis?

2. Rembrandt van Rijn, by Ruyan

Rembrandt van Rijn is considered one of the greatest painters and etchers in Dutch history and well known for his masterful contributions to European Art. His work paved the way for the Dutch Golden Age with innovative and creative pieces that moved away from the Baroque style of the past. Rembrandt achieved great success as a young painter and was respected and popular throughout his life. His ability to portray the human condition with empathy and sincerity marked him as “one of the great prophets of civilization.” His self-portraits are considered to be among his greatest artistic triumphs, offering raw and unadulterated insight into his life. He portrayed himself without vanity, including features such as an enlarged nose, visible blood vessels, and pimples in many areas of his face. In some paintings he depicted several papular lesions, a telangiectatic lesion under his right eye, and a bulbous nose. These signs indicate the presence of an inflammatory dermatosis – which one?


Rembrandt van Rijn (1606-1669)

3. Viktor Yushchenko, by Abraham (old friend of Michael's)

 The political situation of Ukraine in the past decade has created a deeply divided society. One particular incident was the illness of presidential candidate Viktor Yushchenko. After having a rowdy night eating sushi and drinking plenty during a political meeting, Yushchenko's face began to grow a very serious amounts of acne and pockmarks.  Skin colour turned a gluey, greenish-yellow. One eye was partly paralyzed and everything in his face looks swollen. His back ached, his stomach hurt. After a few days of these symptoms he checked himself in to a prestigious clinic in Austria where doctors suggested his symptoms were due to severe pancreatitis due to viral infection. A few doctors worldwide suspected a very different illness that reminded them of patients in a few isolated incidents in italy, and victims and veterans of the vietnam war. What is the likely cause of Yushchenko's deformity?


He's since mostly recovered from the Kafkaesque appearance and illness but his face remains largely scarred.

4. Remus Lupin, by Roberta

Professor Remus John Lupin of the Hogwarts School of Witchcraft and Wizardry secretly sought treatment from Professor Severus Snape for a medical condition. The primary manifestation of Professor Lupin’s disease was hypertrichosis. In addition, Professor Lupin demonstrated a biphasic anagen phase with his hair growing at the normal rate of half an inch each month until the last day of the month when his hair growth rate skyrocketed and his main symptom of hypertrichosis was most apparent. This acceleration in hair growth rate was followed by an accelerated telogen phase, so Professor Lupin’s symptom of hypertrichosis resolved by the first day of the month each month.  What disease did Professor Lupin suffer from, and what mythological creature was he mistaken for in the Harry Potter series?

 
Professor Snape made a potion to treat Professor Lupin from the pictured flower, aconitum (wolfsbane).

5. Paul Klee, by Monica (Michael's mom)

Paul Klee (December 18, 1879-June 29, 1940) was a painter born in Switzerland. The son of a music teacher, he was a talented violinist growing up. As a teenager, his attention turned from music to the visual arts. His style was influenced by expressionism, cubism, surrealism and orientalism, and his signature technique including drawing with a needle on a blackened pane of glass. Klee also experimented with and eventually got deep into color theory. Ad Parnassum is widely considered to be his masterpiece.

Klee was plagued by stomach problems and suffered from weight loss and hardening of the skin, as well as difficulty swallowing and incontinence. His doctors failed to diagnose his true condition, and he was misdiagnosed in 1935 with bronchitis and measles. He was bedridden until 1936, when he resumed painting on a limited basis. He died in June 1940 from cardiac paralysis. He once wrote, “Everything vanishes around me, and works are born as if out of the void. Ripe, graphic fruits fall off. My hand has become the obedient instrument of a remote will.” What was his diagnosis?


Ad Parnassum, by Paul Klee

6. Madame X, by Marissa

Painted in 1884, John Singer Sargent's portrait of Madame X caused a great stir when it was first displayed in a Paris Salon. The portrait is of Virginie Amélie Avegno Gautreau, a socialite born in New Orleans who moved to Paris with her mother and sister after her father died in the Civil War. Her revealing dress and prominent décolletage were perhaps the most provocative features of the painting. Her pale translucent almost bluish-purple tinged skin was considered the epitome of a beautiful complexion in that day.  It is rumored that she ingested small wafers containing this substance (let's  call it substance X) in order to achieve her fair complexion. Exposure to substance X can cause Mee's Lines in the nails. Exposure to substance X can also cause Basal Cell Carcinoma. Other common etiologies of Basal Cell Carcnioma include UV exposure, X rays and scars/chronic inflammation.


Madame X, by John Singer Sargent

7. Salif Keita, by Alex

Salif Keita is a world-famous musician who is said to be a descendant of the founder of the Malian empire, Sundiata Keita, who lived in the 13th century. Although he was born into wealth and status, he was disowned by his family because of this instantly noticeable skin disorder, which is said to be an omen of bad luck in Madinke culture. He eventually fled Mali, taking his group Les Ambassadeurs with him, and eventually moved to Paris. He went on to work with musicians from all over the world, including renowned jazz saxophonist Wayne Shorter and Carlos Santana. Who knows what would have become of Keita if he had not been disowned, though, as one Wikipedia editor pointed out, because of the Malian caste system, “he should never have become a singer, which was deemed to be a griot’s role.” In 2009, he dedicated his album La difference to fellow sufferers of this condition. What kind of deficiency most likely caused his skin disorder?



8. Jean-Paul Marat, by Michael

When Napoleon said "vanity made the revolution; liberty was only a pretext," perhaps he was referring to the man featured in our final case. Jean-Paul Marat was a Swiss physician who in 1789, set his sights to the world of political journalism in favor of France's new revolutionary government. With his self-stylized title of "Friend of the People", he became one of the most vocal supporters of the bloodshed that came to define Robespierre's Reign of Terror, and his daily newspaper columns encapsulted the odd combination of savagery, fraternity, and enlightenment that defined the revolution. Interestingly, most of his political musings were written as he lay in an oatmeal bath, which he used for three years to help treat a severe and debilitating skin condition. The condition started in his late 40s and originated in the anogenital area. It was extremely itchy and at times purulent and blistering, and was sometimes accompanied by headaches, insomnia, polydipsia, and "paranoia". It spread to his entire body, and certainly did not do any favors for a man already considered to be ferociously ugly. Some doctors thought syphilis, other eczema, but a more recent diagnosis based on the late-onset and chronicity lead to speculation that Marat may have also had a certain gastrointestinal disease. What could it be? 

As you would expect, Marat's fiery public persona earned him a few enemies, and in 1793 a young woman named Charlotte Corday stabbed him as he lay in his bath. The event would be immortalized by Marat's friend and fellow revolutionary Jacques-Louis David in one of the most famous propaganda paintings of all time:


The Death of Marat, by Jacques-Louis David


Answers (highlight to see):
1. Actinic Keratosis that underwent acute solar degeneration, possibly to squamous cell carcinoma in situ (Bowen’s disease).
2. Rosacea
3. Chloracne from digoxin poisoning
4. Porphyria, Werewolf
5. Scleroderma
6. Arsenic
7. tyrosinase (albinism)
8. Dermatitis herpetiformis (goes with celiac disease)