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A eRIC N A c a D e m Y OF

D e F M a T O L O G Y

Self-Assessment examination of the American Academy of Dermatology*

Identification No. 883-210

See "Instructions for Category 5(d) CME Credit" on page 33A of the front advertising section.

Instructions: In answering each question, refer to the specific direc- tions provided. Since it is often necessary to provide information in questions occurring later in a series that give away answers to earlier questions, please answer the questions in each series in sequence.

QUESTIONS 1,5

A 35-year-old man comes to you with a 5-year history o f multiple red to red-blue nodules on the superior aspect of his back (Fig. 1). They are oc- casionally painful. He is otherwise in good health.

1. Your differential diagnosis of painful cutaneous tumors should include (Choose as many as are correct. All, some, or none of the answers may be appropriate.) a. dermatofibrosarcoma protuberans b. traumatic neuroma c. leiomyoma d. eccrine acrospiroma e. angiolipoma

In order to establish a definite diagnosis, you obtain a 4 -mm punch biopsy and stain it with hematoxylin and eosin (Fig. 2) and Gomori ' s tri- chrome stain (Fig. 3),

2. The most likely diagnosis now is (Choose the sin- gle best response.) a. dermatofibrosarcoma protuberans b. multiple leiomyomas c. metastatic renal cell carcinoma d. multiple eccrine spiradenomas e. plexiform neurofibroma

3. Solitary, nodular tumors histologically resembling the patient's also occur preferentially in which of

The Self-Assessment examination is supported in part by an educa- tion grant from OWEN Laboratories, Fort Worth, TX.

*The members of the Self-Assessment Committee of the American Academy of Dermatology are: W. Clark Lambert, M.D., chair- man, Ronald J. But'c, M.D., Joseph B. Bikowski~ M.D., Ralph J. Coskey, M.D., Richard L, De Villez, M.D., Ernesto Gonzalez, M.D., Ira H. Gouterman, M.D., Terry M. Jones, M.D., Thomas G. Olsen, M.D., Charles E. Reaves, M.D., Richard K. Scher, M.D., Henry T. Shenfield, M.D., Thomas R. Wade, M.D., and Paul S. Wolfish, M.D.

40A

the following sites? (Choose as many as are cor- rect. All, some, or none o f the answers may be appropriate.) a. Scrotum b. Ear c. Nipple d. Nose e. Labia majora

4. Although it is not entirely diagnostic, a provoca- tion test used to substantiate the diagnosis in this case is (the) (Choose the single best response.) a. histamine injection b. rubbing to elicit Dean's sign c. ice cube test to elicit contraction of the tumor d. rubbing to elicit Darier's sign e. laterally applied pressure to elicit the dimple

sign

The patient asks what will happen if you do not treat these lesions.

5. You tell him that they will (Choose the single best response.) a. resolve spontaneously b. slowly increase in size, with occasional new

lesions appearing c. increase in size with malignant degeneration

occurring in 20% of patients d. increase in size with low incidence of metas-

tasis to regional nodes but rarely beyond e. rapidly undergo widespread metastasis

QUESTIONS 6-15

You see a 30-year-old patient with a persistent verrucous 1 cm granulomatous nodule on the dot- sum of the hand. According to the patient, it has been present for 3 months.

Volume 9 Number 4 October, 1983 Self-Assessment examination 43A

Your differential diagnosis includes many of the infectious granulomas.

For each of the following numbered diseases, choose the single lettered organism most closely related to it. Each lettered item may be used once, more than once, o1" not at all.

a. Mycobacterium tuberculosis b. Mycobacterium marinum c. Blastomyces dermatitidis d. Sporothrix schenc'kii e. Phialophora verrucosa

6. Swimming pool granuloma 7. Verruca necrogenica 8. Sporotrichosis 9. Gilchrist's disease

10. Chromomycosis

For each of the .following numbered diseases, choose the single best lettered treatment. Each lettered item may be used once, more than once, o1" not at all.

a. Isoniazid with ethambutoi with or without rifarnpin

b. Minocycline c. Flucytosine d. Amphotericin B e. Potassium iodide

1 l. Swimming pool granuloma 12. Verruca necrogenica 13. Sporotrichosis 14. Gilchrist's disease 15. Chromomycosis

44A Self-Assessment examination

Journal of the American Academy of

Dermatology

QUESTIONS 16-19

A month-old infant is referred to you for evalu- ation of an eruption in the diaper area. The rash was treated initially with an over-the-counter hy- drocortisone cream and, after failure to respond, was treated with a neomycin cream, after which it became worse. The appearance is shown in Fig. 4. Some of the papules are eroded.

Choose the best answer(s) for each question.

16. The differential diagnosis should include all of the following except (Choose single most appropriate response.) a. syphilis b. granuloma gluteale infantum c. candidiasis d. seborrheic dermatitis e. ammoniacal (diaper) dermatitis

17. Which two diagnostic tests would you best per- form now? (Choose the two best responses.) a. VDRL b. IgM-FTA-ABS (fluorescent treponemal anti-

body) c. KOH (potassium hydroxide) examination d. Culture (Sabouraud's agar) e. Patch tests

Microscopy of a scraping in 10% KOH is shown in Fig. 5.

18. The most likely diagnosis is (Choose the single best response.) a. derrnatophytosis b. candidiasis c. syphilis with secondary candidal colonization d. erythrasma e. granuloma gluteale infantum

Within a week the culture produces the growth seen in Fig. 6.

19. Which of the following medications could be ap- propriately recommended? (Choose as many as are correct. All, some, or none qf the answers may be appropriate.) a. Miconazole b. Ketoconazole c. Clotrimazole d. Tolnaftate e. Nystatin

QUESTIONS 20 and 21

A previously healthy 17-year-old boy was ad- mitted for a 6-day illness characterized by fever, malaise, myalgia, nausea, vomiting, earache, and photophobia, followed by coryza and nonproduc- tive cough. Two days before admission, an erup- tion appeared on his wrists and the dorsa of his feet.

The patient was acutely ill with fever of 39 ° C. His conjunctivae and posterior portion of his phar- ynx were erythematous. A clear nasal discharge was present, and shotty anterior and posterior cervical lymph nodes were palpable. He had rales and decreased breath sounds at the base of his left lung. Skin lesions were concentrated on his feet and wrists, with a few scattered on his trunk, palms, and soles, but his face was spared. The eruption was maculopapular, erythematous, and nonpruritic; some of the lesions became hemor- rhagic after 24 hours.

20. Possible diagnoses include all of the following

Volume 9 Number 4 October, 1983

Self-Assessment examination 47A

except (Choose the single most appropriate response.) a. Rocky Mountain spotted fever b. acute febrile neutrophilic dermatosis (Sweet's

syndrome) c. erythema multiforme induced by Mycoplasma

pneumoniae d. leukocytoclastic vaseulitis e. atypical measles syndrome

Upon further questioning, it is learned that the patient had not traveled recently outside of south- eastern Michigan and had not taken medications. He had been immunized at ages 4 and 5 with diph- theria, pertussis, oral polio, and killed measles vaccines.

Admission laboratory data included a hemo- globin concentration of 12.2 gm/dl; leukocyte count 5,000/ram :~ with 60% neutrophils, 10% band forms, 12% lymphocytes, 1% atypical lym- phocytes, 15% monocytes, and 2% eosinophils; platelet count 105,000/mm a, and lactic dehy- drogenase (LDH), 250 IU/ml. Cold aggluti- nins, VDRL, heterophil, and Proteus OX~.~ titer were negative. A chest roentgenogram showed cardiomegaly and an infiltrate in the posterior segment of the right lower lobe. An electrocardi- ogram showed nonspecific S-T segment changes.

21. Based on this information, which of the follow- ing statements concerning this patient and his dis- ease are true? (Choose as many as are correct. All, some, or none of the answers may be appro- priate.) a. Acute and convalescent measles complement

fixation antibody titers should show a fourfold or greater rise.

b. Tetracycline treatment should be instituted immediately.

c. The disease is most frequent in the winter months.

d. The evolution and morphologic appearance of the eruption permit easy clinical differentiation from Rocky Mountain spotted fever.

e. Pneumonia is frequently seen in this disease.

QUESTIONS 22-24

A 30-year-old white male vegetarian presents with a yellow discoloration of the palms, soles, nasolabial folds, and forehead.

22. Which of the following is the most likely diagno- sis? (Choose the single best response.)

23.

24.

a. Lycopenemia b. Carotenemia c. Addison's disease d. Jaundice secondary to biliary disease e. Carcinoma of the head of the pancreas

Which of the following has (have) been associated with this abnormal pigmentation.'? (Choose as many as are correct. All, some, ot" none of the answers may be appropriate.) a. Diabetes mellitus b. Myxedema c. Excess dietary intake of yellow vegetables d. Gallstones e. Carcinoma of the head of the pancreas

A simple clinical differentiation between this type of pigmentation and jaundice is that in this process there is (Choose the single best response.) a. lack of scleral involvement b. more heavily pigmented sclerae c. intense pruritus d. less severe involvement of the palms and soles e. more marked nail bed changes

QUESTIONS 25-29

At age 43, a 64-year-old Caucasian man, who had a long-standing history of excessive alcohol consumption, first noted a darkening in the color of his urine. He subsequently developed ery- thema, vesiculation, scarring, and hardening of the skin over the acral regions of his body. The disease has been progressive, resulting in atro- phy and imparting a bound-down quality to his skin.

25. Upon physical examination, the only serious diag- nostic considerations were scleroderma and por- phyria cutanea tarda (PCT). Additional physical and historical information that would be useful in reaching a diagnosis incIudes (Choose as many as are correct. All, some, or none of the answers may be appropriate.) a. Raynaud's phenomenon b. calcifications of the skin c. ulcerations of the skin d. hypertrichosis e. dysphagia

26. Useful laboratory studies in the evaluation and management of this patient include all of the fol- lowing, except (the) (Choose the single most ap- propriate response.)

48A Se l f -Assessmen t examtnat ton

Journal of the American Academy of

Dermatology

a Bromsulphalem (BSP) test b gamma glutamyl transpeptldase (T-GTP) test c 5-hour GTT (glucose tolerance test) d Wood's hght exarmnatlon of unne e porphoblhnogen levels m urine

27 All of the following tests reveal elevated values an PCT except (Choose the smgle most approprtate response ) a urine coproporphyrm b urine uroporphyrm c urine porphobdmogen d T-GTP e serum Iron

28 Drugs or chemicals capable of Inducing PCT in- clude all of the following, except (Choose the sin- gle most approprtate response )

29

a predmsone b 2,4,5-tnchlorophenol c chloroqume d hexachlorobenzene e &ethylstllbestrol

Diseases associated w~th cases of PCT may include (Choose as many as are correct All, some, or none of the answers may be approprzate ) a hepatttls b autolmmune diseases c hemochromatosls d retlculoendothehosls e carcmomatosls