70/M Multiple skin lesions

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Case

 70yr Male patient came to opd with c/o skin lesions associated with itching all over the body since 20days.

Pt. was apparently asymptomatic 20days back then the pt developed intense itching over the posterior trunk. then his attender noticed fluid filled lesions over his back The lesion is initially small in size and gradually increased in size as observed by the attender. lesions rupture spontaneously or by scratching leaving out bear skin through which pale watery fluid oozes out which is not blood stained. The skin later got thickened and crusted in the centre.
Then spread to both upper limbs,lower limbs,trunk,face and scalp. He observed that new lesions developed at the sites where the fluid in those lesions had spread.
After 10 days he consulted local doctor as his lesions are not getting any better and took medication( oral steroids) for 2days,following which he developed bilateral upper limb edema involving hands, wrist and forearms which is pitting type.
No h/o fever, redness.
No contact history.

Past history:

No h/o similar complaints in the past.
Not a k/c/o DM, HTN, TB, Asthma, CKD, CHD,Thyroid diseases.
No surgical history.

Personal histoty:  

       Diet- mixed

       Appetite - decreased

       Sleep - inadequate

       Bowel and bladder habits - regular 

        Chronic smoker since he was 10yrs old

        Occasional  alcohol consumption(90ml)

    Stopped smoking and alcohol consumption since 1month.

Family history:

No similar complaints in the family.

General Examination:

                  Pt is conscious,coherent and cooperative.                Thin built, moderately nourished.
 

Vitals:

       Afebrile
       BP -
       Pulse -
       RR -
       Spo2 -
       GRBS -
No signs of pallor, icterus, cyanosis, clubbing,koilonychia,lymphadenopathy

O/E

No local rise of temperature

Multiple hyperpigmented plaques which are irregular and of varied sizes noted over an erythematous background with central crusting all over the limbs, trunk and face.

Skin looks desquamated aroumd the lesions

Oral mucosa - normal
Genital mucosa - normal
Sensation and nerves - normal
Edema - bilateral pitting type involving hands,wrist and forearm.

Systemic examination:

CVS - s1s2 heard , no murmurs

RS - BAE present, NVBS heard,no added sounds

CNS EXAMINATION

HMF normal 

All Cranial nerves intact 

Motor system:

          Tone - normal
          Bulk - normal
          Power -              right                left

                    UL              5/5                  5/5

                     LL               5/5                5/5

          Reflexes-          right               left

          Biceps                +2                 +2
          Triceps               +2                 +2
          Knee                   +2                 +2
          Ankle                  +2                  +2
          Plantar          extensor        extensor

Sensory system examination : normal

Cerebellar signs - intact

Gait - normal

Per abdomen: 

soft, non tender, no organomegaly , no palpable masses

Depending on the clinical condition of the patient the skin biopsy was planned and following investigations were done.: