DERM CASE TTeesstt yyoouurr kknnoowwlleeddggee wwiitthh mmuullttiippllee--cchhooiiccee ccaasseess This month — 9 cases: © 1. Dark, Fuzzy Spots on the Back p.37 5. Longtitudinal Fingernail Bands p.41 rigPhersistent, Pruritic Plaques p.4n2 2. Thin, Concave Fingernails Copp.y38 6. tributio A Stye and Eyelid Swelling p.39 7. White Cheelk PDatcihses , p.43 3. ercia ownload Discolouration of the Legs p.40 m Discolouratiso nc oafn th de Shoulder p.44 4. r Com 8. sed user le o AuthorEi ruption on the Innnear lB uicseep p.45 r Sa ohibited. 9. for perso ot fo d use pr gle copy N authorise rint a sin Un iew and p display, v Case 1 Dark, Fuzzy Spots on the Back A 37-year-old woman presents with several dark and fuzzy spots on her back of several years duration. What is your diagnosis? a. Seborrheic keratoses b. Compound nevi c. Pedunculated nevi d. Dysplastic nevi e. Lentigines Answer Atypical nevi are moles with clinically unusual fea- tures. A biopsy with histopathology will provide the diagnosis of dysplastic nevi (answer d). The concern is that it can be hard to tell whether a dys- People with atypical or dysplastic nevi are at a plastic nevus might already be an early melanoma; slightly higher risk than the general population of hence, they are often biopsied or excised. developing melanoma (especially if they have five They can occur sporadically or can be inherited. or more atypical nevi). These patients should be Atypical nevi are often asymmetric, have fuzzy or educated about sun protection and avoidance, and blurred borders, have variegated or multiple colours, they should be taught how to examine their skin. are bigger than 5 mm in diameter, and/or may They should also have their skin periodically change in size or colour over time (these are reviewed by a physician. referred to as the ABCDE rules). Sporadic, atypical nevi are much more common in fair-skinned per- Benjamin Barankin, MD, FRCPC, is Medical Director and Dermatologist at the Toronto Dermatology Centre in sons, especially if they have had a fair bit of sun or Toronto, Ontario. tanning salon exposure. The Canadian Journal of CME / February 2014 37 DERM CASE Case 2 Thin, Concave Fingernails An 89-year-old, Caucasian woman is admitted to the coronary care unit with a complaint of chest pain radiating to her back. She was recently diag - nosed with an ascending aortic aneurysm. Physical examination is remarkable only for hypertension and thin fingernails that have a concave appear - ance. CT reveals progression of her ascending aneurysm and a new descending thoracic aortic dis - section. The patient’s aortic dissection is managed medically with improvement in her BP control, and a surgery is planned to repair her ascending Figure 1: Thin Fingernails Figure 2: Thin Fingernails with a aneurysm. Distinguishable Concave Appearance What is your diagnosis? a. Hyperthyroidism should also consider gynecological causes of blood b. Iron deficiency anemia loss. Other causes include renal failure, pulmonary c. Psoriasis hemosiderosis, and intravascular hemolysis. d. Endocarditis Diagnosis is based on a thorough history and phys - e. Bronchiectasis ical examination. Laboratory investigations consistent with iron deficiency anemia include a microcytic ane - Answer mia, decreased reticulocyte count, low serum iron, This patient exhibits koilonychia, commonly referred to increased total iron binding capacity, low transferrin as spoon nails, owing to the upward curvature of the saturation level, and low serum ferritin. Treatment distal nail plate, which gives the nail a spoon-like should be aimed at correcting the underlying cause. The appearance. This abnormality is most often associated patient did acknowledge a past history of iron deficien - with iron deficiency anemia (answer b) . There are cy anemia. other causes, including trauma, hemochromatosis, sys - Brent M. McGrath, MD, MSc, PhD, is an Associate temic lupus erythematosus, hypothyroidism, nail-patel - Chief Resident in the Department of Medicine at Saint la syndrome, and occupational exposure to petroleum- John Regional Hospital in Saint John, New Brunswick, based products. It is often a normal finding in infants. and Dalhousie University in Halifax, Nova Scotia. Koilonychia is a cutaneous manifestation of a systemic Nicholas A. Forward, MD, MSc, is a Resident in the disease, rather than a primary nail abnormality. Department of Medicine at Dalhousie University in Halifax, Nova Scotia. Iron deficiency anemia usually results from blood loss, most often from the gastrointestinal tract. Other Corey Stevens, BSc, is a Medical Student at Dalhousie Medicine New Brunswick in Saint John, New gastrointestinal conditions commonly implicated Brunswick, and the Faculty of Medicine at Dalhousie include celiac sprue, gastritis, inflammatory bowel University in Halifax, Nova Scotia. diseases, and diets deficient in iron. In women, one 38 The Canadian Journal of CME / February 2014 DERM CASE Case 3 A Stye and Eyelid Swelling A 14-year-old male presents with a stye on his right eyelid, which first appeared a few days ago. He later noticed swelling of the same eyelid. He denies trauma, blurry vision, or pain. What is your diagnosis? a. Dacryocystitis b. Orbital cellulitis c. Periorbital cellulitis d. Angioedema e. Blepharitis movement, chemosis (conjunctival edema), and even proptosis (bulging forward of the eyeball). Answer Periorbital cellulitis is usually treated with a 7 to 10 Periorbital cellulitis (commonly known as preseptal day course of oral antibiotics, allowing for coverage cellulitis) (answer c) usually occurs from exogenous of Staphylococcus aureus and Streptococcus pyo - sources such as trauma, insect bites, and infections. genes , which are the two most common pathogens It can also be an extension of an eyelid infection, such involved. Antibiotic choices include cephalexin, clin - as a chalazion or hordeolum. On examination, damycin, and amoxicillin/clavulanate. Further investi - patients with periorbital cellulitis will have an erythe - gation and treatment may be warranted if there is fail - matous, swollen, and painful eyelid. Patients may also ure to improve within two to three days, and there have a mild fever. The eyeball itself is usually unaf - should be close vigilance for the development of fected, unless it extends to an orbital cellulitis. One orbital cellulitis. way to differentiate between periorbital and orbital Kimmy Goyal, MD, CCFP, ABFM, is a Family Doctor in cellulitis is that the latter can be accompanied by a Brampton, Ontario. decrease in vision, less reactive pupils, pain with eye Fenny Goyal, MD, is a Medical Graduate from the Windsor University School of Medicine in Cayon, Saint Kitts-Nevis. The Canadian Journal of CME / February 2014 39 DERM CASE Case 4 Discolouration of the Legs A 62-year-old female presents with reddish-brown dis - colouration on the right and left pretibial areas of her legs. On examination, there are nonblanching, red, pin - point dots within the lesions. What is your diagnosis? a. Pigmented purpuric dermatoses b. Thrombocytopenic purpura c. Stasis dermatitis d. Psoriasis Answer Pigmented purpuric dermatoses (PPD) (answer a) are characterized by a reddish-brown discolouration of the skin that occurs primarily on the lower extremities and occasionally extends to the lower Drug-induced cases of PPD often have a rapid trunk and upper extremities. The four clinical vari - onset and a quick recovery, upon discontinuation of ants of PPD are known as Schamberg disease, the drug; however, the majority of PPD cases are Majocchi disease, Gougerot-Blum disease, and idiopathic, insidious, and long lasting. Onset is Lichen Aureus. While the etiology is not entirely more likely to happen between the ages of thirty and known, it is believed that the primary mechanism sixty, and males are affected more often than is cell-mediated immune injury of blood vessels females. PPD can be cosmetically disfiguring, and with subsequent red blood cell extravasation. patients often seek treatment for the lesions. Degradation of the erythrocytes and the formation Compression stockings may be help with PPD, and of hemosiderin are believed to be the primary caus - topical steroids may be helpful if dermatitis occurs. es of the characteristic brown discolouration. Other Ereni Neonakis is a Research Assistant in the Division of etiologic factors that increase the incidence of PPD Dermatology at Dalhousie University in Halifax, Nova are trauma, pressure, and certain drugs, such as Scotia. NSAIDs and diuretics. Richard Langley, MD, FRCPC, is a Professor of Dermatology and Director of Research in the Division of Dermatology at Dalhousie University in Halifax, Nova Scotia. 40 The Canadian Journal of CME / February 2014 DERM CASE Case 5 Longitudinal Fingernail Bands A 20-year-old female is concerned about white and red longitudinal bands on her fingernails as well as some flat-topped papules in the periungual areas. She also has some greasy, hyperkeratotic papules on her trunk. Her father has a similar eruption on his back and legs. What is your diagnosis? a. Seborrheic dermatitis b. Tuberous sclerosis c. Melanonychia striata d. Grover’s disease e. Darier’s disease Answer Darier disease (answer e) , also known as keratosis yellow-brown, brown, or skin-coloured; and feel like follicularis, is an autosomal dominant disorder char - coarse sandpaper. Over time, lesions become mal - acterized by the loss of intercellular adhesion (acan - odorous secondary to bacterial colonization or infec - tholysis) and abnormal keratinization of the epider - tion. Papules, fissures, and ulcers may develop on the mis, nails, and mucous membranes. The disease is palate, buccal mucosa, or tongue. Ocular features caused by mutations in the ATP2A2 gene that encodes include keratotic plaques on the eyelid and Sjögren’s a sarco/endoplasmic reticulum Ca 2+ adenosine syndrome. triphosphate isoform 2 protein (SERCA2). Patients The disease is chronic and unremitting. Treatment typically present when they are between 6- and 20- options include emollients, topical corticosteroids, years-of-age; onset peaks between 11- and 15-years- topical calcineurin inhibitors, topical 5-fluorouracil, of-age.