Case of the month: What is wrong with this middle-aged man with pityriasis rosea?

In our latest in the series, Dr Donagh McDonagh asks what could be wrong with this 43-year-old man with a rash and a groin lump. Suggest your answers below the line!

A 43-year-old male contacted his GP surgery with a single groin lump and a skin rash. Practice staff had invited the patient to submit a picture of the rash (see image below) before the GP returned the call.

The GP reviewed the images and spoke with the patient, with the history reported as:

• The rash was present for three days, with an initial patch on stomach and an occasional itch. The working diagnosis from images and history was that of pityriasis rosea.
• The groin lump was left-sided unilateral, sized ‘between a pea and a plum’, painless, and was present for one week.
• Sexual history included three homosexual partners (two protected, one unprotected), anal intercourse in last 12 months.

The patient was invited to attend for face-to-face appointment that morning. When seen, the salient exam findings were:

1. Review of systems: states unintentional weight loss, which triggered some concern. Weight was 66kg, with a BMI of 21. The last GP-recorded weight was 75kg 40 months previously (representing a 13% loss).

2. Rash: probable pityriasis rosea with ‘herald’ patch at epigastrium, mainly truncal, limbs spared. The only other skin finding was haemangioma birthmark on his right wrist.

3. Groin: a single 1x2cm non-tender, left-sided groin node with some other shotty non-pathological feeling nodes. The gland didn’t have the appearance of lymphogranuloma venereum.

4. Haematology: no hepatosplenomegaly or lymph nodes at other body sites.

5. Sexual history: patient was a ‘top’ – anoinsertive intercourse. His last GUM/STI check was two years previously in another jurisdiction.

Patient was advised that GP would need to investigate both weight loss and the groin lump.

We sent for:

• Haematology FBC; ESR.
• Biochemistry CRP; U&E; LFT; TFT; glu; HbA1c.
• Sexual health screening tests that can be done from a GP surgery (bloods and urine) were sent.

The tests available at that time showed:

• Next-day tests showed (abnormal) ESR 50s, CRP 30s; slight increased WCC (12), ANC(7), lymph and plt (490s). Normal – glu, TFT , U&E, LFT, Hba1c.
• Several days later, urine result negative for gonorrhoea and chlamydia; bloods HIV & Hep B&C negative.
• Two weeks later on repeat testing, ESR and CRP had marginally improved (CRP 33; ESR40) but the patient had developed a mild anaemia Hb=122 so was recalled for another face-to-face appointment.

When seen 13 days after the initial consultation, the patient reported mild upper respiratory type symptoms of sore throat and blocked nose as well as night sweats. There was no haematuria or rectal bleeding. The salient findings were :

1. Vitals normal.

2. Chest, throat, nose, abdomen and rectal exam normal.

3. No new rashes.

Appropriate tests and repeats for anaemia were organised, along with chest X-ray.

What do you think the diagnosis is at this stage?

Put your suggestions in the comments below. Answer to be revealed in the coming weeks…