(BMJ)—A man in his 80s presented with a 10-day hx of upper abdominal pain preceded by two months of itchy, thickened, and hyperpigmented lesions on his face, neck, chest, and extensor surfaces of the limbs. Exam: diffuse velvety skin lesions and seborrheic keratoses evident. What’s the dx?
malignant acanthosis nigricans
Becker melanosis
Addison disease
melasma
You are correct. This appearance, known as the Leser-Trelat sign, is characteristic of malignant acanthosis nigricans. Acanthosis nigricans is characterised by velvety, hyperpigmented, papillomatous lesions, usually in skin flexures and associated with obesity or insulin resistance. Rarely, acanthosis nigricans can be associated with internal malignancy. When associated with malignancy, acanthosis nigricans may develop more rapidly than with non-malignant causes, and skin lesions can occur in unusual sites such as the oral cavity, palms, and soles.

BMJ 2023;381:e073424
(BMJ)—This woman in her 40s presented with a 10-month history of cough and was found to have a saddle nose deformity. She had a 15-year history of recurrent chronic rhinosinusitis and refractory otitis media. Exam showed an almost complete loss of nasal bone and septal cartilage, resulting in complete collapse of the nasal bridge with retraction of the nasal tip. What’s the dx?
nasal trauma
granulomatosis with polyangiitis
relapsing polychondritis
congenital syphilis
You are correct. Granulomatosis with polyangiitis was diagnosed based on positive immunological test results for c-ANCA (anti-neutrophil cytoplasmic antibodies) and PR3-ANCA (anti-proteinase 3 antineutrophil cytoplasmic antibody). Granulomatosis with polyangiitis can present with upper and lower respiratory tract symptoms with renal involvement, and biopsy may be needed to confirm a diagnosis. Differential diagnoses for saddle nose include nasal trauma, congenital syphilis, and relapsing polychondritis.

BMJ 2023;381:e073481
(BMJ)—This woman in her 20s presented with a painless, fluctuant swelling under her tongue that had increased over 2 months and affected her speech and ability to chew. What's the dx?
ranula
lymphangioma
mucocele
cystic hygroma
You are correct. CT confirmed a ranula originating from the L sublingual salivary gland. Ranulas can be caused by trauma, infection, or inflammation of the sublingual salivary duct and tend to occur in teenagers and young adults. These cysts may not cause symptoms, but large ones can affect speech, swallowing, and even respiration as they displace the tongue. This patient underwent surgical excision of the ranula and L sublingual salivary gland with no recurrence.

BMJ 2023;382:e074480
Can you identify this pill?
atazanavir
cefaclor
tolterodine
loxapine
You are correct. Atazanavir is a protease inhibitor indicated for the treatment of HIV infection in adults and children.

As a reminder, you can use the Pill ID feature to identify a pill based on its imprint code or physical characteristics, including shape, color, and scoring. Find Pill ID in the epocrates app or on epocrates web.
[Source: Pill ID]