A 65-year-old retired male (Fitzpatrick phototype II) previously healthy except for a distant history of basal cell carcinoma presented to our dermatology clinic with a two-day duration of a rash. The lesions were first noticed on his chest, upper extremity and back []. The rash was extremely pruritic resulting in insomnia for the previous 2 nights which went unrelieved despite oral diphenhydramine. Also concerning to him and his wife was the whip like nature of the rash which was somewhat linear and run vertically right down his back in a manner unlikely to be produced by simple excoriation. In addition, he denied reaching for or scratching his back in any manner. Review of systems was negative, and he denied any recent history of travel, similarly sick contacts or recent outdoor contactants or change in body soaps or laundry detergents.\nHe denied any prior history of similar rashes and his past medical history was non-contributory. A detailed exposure history revealed the patient had eaten mushrooms 48 hours ago during dinner at a Chinese cuisine buffet. He admitted to ingesting great quantities of a medley of cooked and raw mushroom including the Shiitake mushroom variety.\nPhysical examination was striking with a truncal dominant but generalized rash in a centripetal distribution (). The lesions consisted of raised, relatively uniform erythematous papulovesicles arranged in linear arrangement. Close-up views [] confirmed the papulo-vesicular nature of the rash with multiple small papules grouped both along the breadth and length of each linear streak within an erythematous background.\nGiven the clinical history and presentation the diagnosis was consistent with a shiitake dermatitis. Flagellate patterns of eruption have also been noted in drug reactions particularly to bleomycin, peplomycin (a bleomycin derivative), docetaxel, adult-onset Still’s disease, and dermatomyositis [].\nThe patient was put on a mid-potency topical steroid (Triamcinolone 0.1% ointment applied to affected areas twice daily). The rash resolved within 1 week. It has been reported that shiitake dermatitis can also resolve spontaneously.
A 45-year-old woman was admitted to our heart center with severe mitral stenosis and left atrial clot. The patient gave a history of shortness of breath on minimal exertion for one week and no cerebral symptoms, including headache, dizziness, transient ischemic attacks, or strokes. She was found to be fully conscious, alert, and oriented with stable vital signs. Blood pressure was 110/80 mmHg, and diastolic murmur was audible over the mitral area. Physical examination revealed intact cranial nerves, motor power, and sensation. There was no evidence of vasculitis such as Osler’s nodes, Jane way pad, palmer erythema, or cyanosis of fingers. Blood investigation showed an erythrocyte sedimentation rate (ESR) of 4 mm with no leukocytosis and a white blood cell (WBC) of 10.000 mm3. The electrolytes and kidney and liver function were within normal limits. Chest X-ray showed prominence of the left cardiac border due to left atrial enlargement. Electrocardiography was indicative of no change, but two–dimensional echocardiography revealed a large bulky non-mobile thrombosis in the left atrium with severe mitral stenosis. The mitral valve area was 0.6 cm2, and the other cardiac valves were normal. Pre- and postoperative laboratory measurements included negative antinuclear antibodies and rheumatoid factor, and elevation of C4 & C3 components of complement; in addition, HBS Antigen (especially in polyarteritis nodosa) was negative.\nThe patient underwent open heart surgery via the ascending aorta and bicaval cannulation. The aorta was cross-clamped, and the heart was arrested with cold cardioplegia by achieving systemic hypothermia at 30 °C on the cardiopulmonary bypass. Intraoperatively, the stenotic mitral valve was found to have a bulky clot attached to the valve and wall of the left atrium. The diseased mitral valve and the clot were excised, and the left atrial cavity was irrigated with copious amounts of normal saline and a valve was thereafter implanted. The left ventricle was then filled completely with saline and blood and fully deaired. The patient was weaned successfully off cardiopulmonary bypass with inotropic support and transferred to the intensive care unit. After 6 hours, blood pressure dropped and central venous pressure elevated and the extremity became cool and cyanotic. Inotropic support was commenced with dobutamine and adrenaline (2 and 1 mic/kg/min, respectively). On the third postoperative day, the inotropic drugs were tapered and blood pressure stabilized. By this point, however, the cyanosis had changed to gangrene and on the 12th postoperative day the acral part of the extremity was amputated and the specimen was sent for histopathological examination. In the histopathological examination, there was only non-specific vasculitis with thrombosis. The patient did not regain full consciousness on the following morning and was found to be quadriplegic with non-voluntary movements of the four limbs and face. The eyes could move only on the vertical plane, with both pupils having become small and fixed. After 72 hours, she managed to respond to questions only by blinking or moving her eyes vertically. Brain MRI revealed multiple infarction of the brainstem. Prolonged ventilatory support was maintained and eventually a tracheostomy was performed to facilitate tracheobronchial suctioning and weaning. Acute renal failure with anemia was managed and the kidneys recovered completely. However, the patient remained in this locked-in state for 4 weeks with no neurological improvement despite all ventilatory, nutritional, and nursing support. She eventually expired from hepatic failure and generalized sepsis.