CASE:
A healthy 42-year-old female with no known medical history or allergies presented to our telemedicine service with a complaint of multiple bug bites. She stated that four days prior to evaluation she participated in a family picnic which was infested with mosquitoes and subsequently experienced multiple bites. She self-medicated with diphenhydramine and experienced mild symptomatic relief yet noted that the lesions continued to progress. A picture of the patient’s lesions demonstrated small, well demarcated papules without any adjacent erythema or convalescence. Multiple lesions were noted on the patient’s hands, arms, and chest. A presumptive diagnosis of multiple bug bites was made, and the patient was advised to initiate a combination of long and short acting antihistamine therapy for symptomatic management, with a plan to follow up with our service if she did not improve within 12 to 24 hours.
The patient called six hours later and described worsening swelling and erythema of her lesions. She uploaded images demonstrating target lesions on her hands, arms, and chest, with a small amount of desquamation of three lesions on her hands. A presumptive diagnosis of Erythema Multiforme was made, and Acyclovir and a Medrol dose pack were initiated. With further exploration of the patient’s history, she recalled starting CBD capsules for insomnia four days prior to assessment, and a new medication for alopecia treatment ten days prior.
DISCUSSION:
The patient presented with a common telemedicine condition, rash, which is consistently among the top 15 evaluated by our service. This case demonstrates that even common complaints in clinical telemedicine services can be indicative of more rare disease states, and that physicians should maintain a high degree of clinical suspicion for these possibilities when a patient’s presentation is atypical for the given concern or diagnosis.
Presumably the E. Multiforme was a reaction to one of the new medications that the patient had recently initiated. This additional history was elucidated only upon follow up evaluation, when it became clear that the lesions in question were unrelated to bug bites. The ability of the patient to follow up after a routine telemedicine consultation was integral to arriving at the correct diagnosis and managing the patient appropriately. Whereas many telemedicine companies perform on demand services on a one-time basis, MediOrbis has a follow – up pathway to our consultations to ensure that patients who have challenging diagnostic or management considerations can be followed longitudinally, thereby providing the highest level of remote care in the remote outpatient setting.
General telemedicine services are typically provided by clinicians trained in internal medicine, emergency medicine or family practice. Few telehealth companies outside of MediOrbis provide a comprehensive panel of specialists to diagnose and treat rare or complex diseases. While this dermatological condition was diagnosable by the primary team, it was reassuring to have the support of trained sub – specialists to assist in diagnosis and treatment of specialty conditions.
Clinically, while there are case reports of CBD – related E. Multiforme- like reactions, it is still a rare entity that warrants further analysis (see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7053463/; https://cdn.ymaws.com/www.aocd.org/resource/resmgr/jaocd/contents/volume32/32-02.pdf). With the proliferation of CBD – related commercial and medical products, clinicians should be advised to have a high degree of clinical suspicion for these uncommon manifestations, as even rare reactions will become more prevalent.
Illustrative pictures:
https://www.gogllgo.top/products.aspx?cname=identifying+insect+bites+pictures&cid=50
https://www.nidirect.