Coccidioidomycosis (AKA “Valley fever”) is a primary pulmonary infection via airborne spores released from coccidioides immitis in the soil. Reactive cutaneous eruptions resulting from the pulmonary infection are difficult to diagnose because skin biopsies do not contain the organism. We present an adolescent male with primary pulmonary C.immitis infection manifesting with biopsy proven subcorneal pustular dermatosis. Serological studies revealed increasingly positive titers for coccidioidomycosis and symptoms resolved promptly following initiation of systemic antifungal therapy. Our unique case presentation illustrates subcorneal pustular dermatosis as a reactive eruption owing to primary pulmonary coccidioidomycosis. An association between the two conditions warrants further investigation.

Necrolytic acral erythema (NAE) is a rare cutaneous sign of hepatitis C virus infection and has recently been linked to zinc deficiency. It presents as well-demarcated erythematous plaques in a sandal-like distribution on the dorsal feet with psoriasiform epidermal hyperplasia on histology. Our patient reported a 9-month history of progressive bilateral lower extremity erythema, swelling, erosions, and nail dystrophy that failed to improve despite multiple courses of antibiotics for presumed lower extremity cellulitis. Serum studies revealed zinc deficiency. This case supports the association of NAE with both HCV infection and zinc deficiency and highlights the pitfalls in the diagnosis of chronic unrecognized NAE. Suspected cases of NAE should prompt evaluation for underlying HCV and zinc deficiency to avoid treatment delay and associated complications.

Psoriasis is a chronic inflammatory disease, evolving from a complex interplay of genetic and environmental factors. In the recent years, we have seen much progress in understanding the immunopathogenesis of psoriasis, paving the way for new therapies with biologics. Currently, the most commonly used biologics in psoriasis are TNF inhibitors etanercept, infliximab and adalimumab, and the IL-12/23 inhibitor ustekinumab. As TNF inhibitors are contraindicated in patients with multiple sclerosis, ustekinumab remained the only biologic available for these patient before the recent approval of Secukinumab, an IL-17A inhibitor. Herein we report two patients with multiple sclerosis and comorbid psoriasis successfully treated with ustekinumab without progression of their multiple sclerosis. Our cases demonstrate that ustekinumab is a reasonably safe choice in this patient population. We also briefly reviewed new therapies currently under investigation, which will undoubtedly further expand our armamentarium for the treatment of psoriasis in patients with neuromuscular diseases.

Complications from radiation exposure during fluoroscopic guidance of cardiac catheterization may occur. With repeated procedures, the risk for cutaneous injuries increases. Herein, we describe a 59-year-old man with extensive coronary artery disease, who had undergone multiple revascularization procedures and developed a non-healing ulcer on his left inferior scapula. The patient’s medical history, physical exam findings, and histopathology gave clues to a case of radiation-induced dermatitis and necrosis.