(BMJ) - A 72-yo woman presented with an erythematous rash on her abdomen with induration and nodules. A biopsy confirmed the diagnosis. What is it?
Contact dermatitis
Herpes zoster
Caput medusae
Lymphangitis carcinomatosa
Erysipelas
You are correct. The patient was diagnosed clinically with lymphangitis carcinomatosa, inflammation of lymphatics as a result of malignancy. Skin biopsy confirmed metastatic adenocarcinoma from an undiagnosed left breast cancer.
(BMJ) - A 36-yo man with HIV, Pneumocystis jirovecii pneumonia, and a CD4 count of 23 presented with an itchy rash on his hands, ears, and scalp. Other family members also had itchy rashes for months. What is the diagnosis?
Crusted scabies
Darier disease
Contact dermatitis
Bed bug bites
Lichen planus
You are correct. Crusted, or Norwegian, scabies usually occurs in immunocompromised hosts and is highly infectious. In contrast to ordinary scabies in an immunocompetent patient in whom 10 to 15 mites might be found, thousands of mites may be detected in the crusted variant. The patient was treated with permethrin and ivermectin.
(BMJ) – A 25-yo man w/ short bowel syndrome received several IV abx and antifungals for Hickman line sepsis. Within 48 h, he developed a well-demarcated, exfoliative rash on his buttocks. No other inciting factors were present. What is it?
Erythroderma
Contact dermatitis
Baboon syndrome
Thermal burn
Tinea corporis
You are correct. The distinctive appearance of this rash is consistent with systemic drug-related intertriginous and flexural exanthema, also known as baboon syndrome. Several drugs, mainly antibiotics, are reported triggers. The condition is usually self-limited upon withdrawal of the offending agent.
(BMJ) – An 82-yo man presented w/ acute onset throat pain and dysphagia upon wakening. His wife recalled him suddenly beginning to snore the night before. PMHx: A-fib. Meds: warfarin. Labs: INR 3.4. What is the diagnosis?
Aphthous ulcers
Uvular hematoma
Behcet syndrome
Oropharyngeal cancer
Strep pharyngitis
You are correct. This patient had a uvular hematoma secondary to anticoagulation. Symptoms improved after warfarin was stopped and dexamethasone was initiated. This case highlights the importance of considering airway hematomas among the differential dx in pts presenting w/ sx suggestive of upper airway obstruction. The acute onset of snoring also should not be ignored.
(BMJ) – A 48-yo woman presented with a presumed verruca on the underside of her second toe. The lesion had not responded to topical or oral antibiotics and was acutely tender, macerated, and hyperkeratotic. What is it?
Squamous cell carcinoma
Tinea pedis
Prurigo nodularis
Spider bite
Acral lentiginous melanoma
You are correct. Histologic examination revealed an invasive, well-differentiated squamous cell carcinoma (SCC) w/ a tumor thickness of 4.7 mm. Toe amputation was necessary for complete excision. The warty morphology of SCC on the sole may lead to misdiagnosis as verruca vulgaris. Urgent investigation is needed if there is any clinical uncertainty.
(BMJ) - A 91-yo woman w/ a family hx of breast cancer presents w/ redness of left breast and nipple x 1 yr. Exam: red, crusty nipple-areolar complex w/ nipple destruction. A 4-wk trial of steroid cream did not lead to improvement. What is the diagnosis?
Actinic keratosis
Eczema
Impetigo
Malignant melanoma
Paget disease
You are correct. Paget disease of the nipple is a rare form of breast carcinoma. Core bx and nipple skin bx confirmed ductal carcinoma in situ w/ Paget disease. The pt had a left mastectomy. Suspicious features of Paget disease include presentation at age >50, nipple-areolar complex involvement, nipple destruction, and no improvement from a 4-wk trial of steroid cream.
(BMJ) - An 82-yo man c/o 10 days of pain and color change in his tongue associated w/ a headache. Exam: grey-black discoloration of distal tongue and scalp tenderness. Labs: elevated inflammatory markers. What is the diagnosis?
Methamphetamine abuse
Giant cell arteritis
Syphilis
Necrotizing ulcerative gingivitis
Oral melanoma
You are correct. Giant cell arteritis (GCA) is the most common cause of tongue necrosis. The patient was started on high-dose oral corticosteroids and a temporal artery biopsy confirmed GCA.
(BMJ) - A 20-yo female horse rider presented w/ painful lesions on her outer thighs during winter for 5 yrs. Exam: red, indurated, tender plaques on lateral thighs. Labs: vasculitis screen, serum cryoglobulins, and cold agglutinins all normal. What is the diagnosis?
Erythema chronicum migrans
Tinea corporis
Lichen planus
Frostbite
Equestrian perniosis
You are correct. Equestrian perniosis (EP) occurs on the thighs and buttocks of female horse riders in cold weather. In this patient, skin biopsy from the affected area confirmed perniosis w/ lymphocytic vasculitis. Wearing warm, loose clothing, avoidance of cold, and use of oral nifedipine or pentoxifylline may be helpful.