DERM CASE Test your knowledge with multiple-choice cases This month – 8 cases: 1. A Tender Nipple p.53 5. Asymptomatic Papules p.58 2. A Bluish Lesion p.54 6. Rough Bumps p.59 3. Various Comedones p.55 7. A Rapidly-Growing Nodule p.61 4. A Sore Throat p.56 8. A Horn-Like Protrusion p.62 Case 1 A Tender Nipple This 51-year-old woman noted a tender eruption on her left nipple area over a six month period of time. Recently, papules have developed on her breast. What is your diagnosis? a. Bowen’s disease b. Intraductal carcinoma c. Psoriasis d. Contact dermatitis e. Lichen planus Answer While lichen planus (answer e) is most recognized as a widespread eruption, it can at times involve In this case, the breast shows characteristic clini - only a single area of the skin, scalp, mucous mem - cal features of lichen planus. branes or nails. The condition is felt to be a T cell- Treatment is often symptomatic using topical mediated autoimmune disorder. steroids.tM©ore widespread involvemieont nmight When mucous membranes are involved, thre iigncluhde oral steroids or metronridiabzolue. Ltichen planus eruption may be asymptomatic or tender. Wphenyskin may be self-limited witsh ttime, oftedn, leaving some o al D wnloa is involved, varying degrees of itchCensue. degreerocf poist-inflamamnatdoory hyperpigmentation. me sers c se m ised u onal u Characteristically, the lesions are: Co uthor pers or ed. A py for • violaceous, ale ohibit le co r S se pr a sing • polygonalf-sohaped andised u print ot uthor and • Nflat-toppedU. na y, view displa The surface may be shiny or have fine white lines Stanley Wine, MD, FRCPC, is a Dermatologist in North called “wickham’s striae.” York, Ontario. The Canadian Journal of CME / May 2008 53 DERM CASE Case 2 A Bluish Lesion A 10-year-old boy presents with an asymptomatic, bluish, soft, compressible lesion on the right thigh since birth. It gets bigger in an upright position. What is your diagnosis? a. Venous malformation b. Mongolian spot c. Capillary hemangioma d. Pilomatricoma Answer Venous malformation (answer a) is a slow-flow vas - cular malformation present at birth. The lesion is soft, compressible, non-pulsatile and deep blue in colour. Expansion with dependent positioning is a Chronic localized intravascular coagulopathy may unique feature. occur due to consumption of clotting factors. Giant Histologically, the lesion is composed of thin- venous malformations may be associated with platelet walled vessels or sinuses lined with endothelium and sequestration, which may lead to intravascular coagu - surrounded by a fibrous connective tissue stroma. lopathy or thrombocytopenia (Kasabach-Merritt syn - These vessels or sinuses drain to normal adjacent drome). Venous malformations in the limb may be conducting veins. They may involve skin, subcuta - complicated by osteoporosis, diaphyseal thinning and neous tissue and mucosa and may permeate deeper lytic lesions. structures, such as muscles. Large venous malformations can be cosmetically Venous malformations are usually segmental or unsightly and may lead to psychological disturbance. focal. Most lesions are asymptomatic. They may Most venous malformations are isolated, although become painful as a result of entrapment and com - they may occur in association with Maffucci syn - pression of nerve fibres or from venous stasis and drome and blue rubber bleb nevus syndrome. thrombosis. Phleboliths are the hallmarks of venous malforma - Alexander K. C. Leung, MBBS, FRCPC, FRCP (UK and Irel), is a Clinical Associate Professor of Pediatrics, tion and result from local venous thrombosis. Other University of Calgary, Calgary, Alberta. possible complications include: Albert Y. F. Kong, MBBS, FRCP (Edin and Glasg), • ulceration, FRCPCH, is a Clinical Associate Professor of Family • infection and Medicine, the Chinese University of Hong Kong, Hong • hemorrhage. Kong, China. 54 The Canadian Journal of CME / May 2008 DERM CASE Case 3 Various Comedones A 21-year-old male presents with various come - dones, papules, nodules and cysts on his back. He is otherwise healthy, but is bothered by the appearance and occasional tenderness. What is your diagnosis? a. Rosacea b. Pustular psoriasis c. Acne vulgaris d. Folliculitis e. Tuberous sclerosis Answer Acne vulgaris (answer c) affects approximately 90% of people at some point in their lives. It presents as: trial of oral tetracycline-family antibiotics along with • non-inflammatory comedones ( i.e. , blackheads topical therapy is reasonable. If non-responsive, either and whiteheads), a different antibiotic can be tried, or oral isotretinoin • papules, should be considered. • pustules, • nodules and Benjamin Barankin, MD, FRCPC, is a Dermatologist, • cysts. practicing in Toronto, Ontario. It typically affects the face, upper chest and back, with occasional upper arm involvement. The key factors underlying development of acne are: • follicular epidermal hyperproliferation and plugging, • excess sebum, • involvement of Propionibacterium acnes bacteria and ® • subsequent inflammation. Various treatment options are employed, but gener - ally, if there is trunk involvement, oral systemic thera - py is required. In this gentleman, a two- to three-month Helps prevent neural tube defects* with 1 mg of folic acid *When taken daily prior to becoming pregnant and during early pregnancy. Product Monograph available upon request Wyeth Consumer Healthcare Inc. Mississauga, ON, Canada L4Z 3M6 DERM CASE Case 4 A Sore Throat This lady presented with sore throat, low grade fever, anorexia, malaise, cervical lymphadenopathy and splenomegaly. Her complete blood count revealed mild anemia. What is your diagnosis? a. Follicular tonsillitis b. Infectious mononucleosis c. Tonsillar tumour d. Quinsy Answer Infectious mononucleosis (glandular fever) (answer b) is a common disease in young adults, although patients may be of any age, which may Treatment includes: pass unnoticed or cause acute illness—rarely fol - • bed rest, lowed by months of lethargy. It is caused by • avoidance of alcohol and Epstein-Barr virus (EBV), which preferentially • rarely, recommended prednisone. infects B lymphocytes. There follows a prolifera - Complications include low spirits, depression tion of T cells (the “atypical” mononuclear cells) and lethargy, which may persist for months. which are cytotoxic to EBV-infected cells. Although rare, other complications include throm - Blood film shows a lymphocytosis with many bocytopenia, ruptured spleen, upper airway obstruc - atypical lymphocytes ( e.g. , 20% of all white blood tion (may need observation in intensive therapy cells). Such cells may be seen (usually in fewer unit), secondary infection, pneumonitis, aseptic numbers) in many viral infections (especially meningitis, Guillain-Barre syndrome, renal failure, cytomegalovirus), toxoplasmosis, drug hypersen - lymphoma and autoimmune hemolytic anemia. sitivity, leukemias, lymphomas and lead intoxica - Hayder Kubba graduated from the University of tion. Baghdad, where he initially trained as a Trauma Heterophil antibodies develop early and disap - Surgeon. He moved to Britain, where he received his FRCS and worked as an ER Physician before pear after around three months. These antibodies specializing in Family Medicine. He is currently a agglutinate sheep red blood cells. Family Practitioner in Mississauga, Ontario. 56 The Canadian Journal of CME / May 2008 DERM CASE Case 5 Asymptomatic Papules This 10-year-old child presents with asymptomatic, skin-coloured papules with surrounding eczema. What is your diagnosis? a. Chickenpox b. Warts c. Psoriasis d. Molluscum contagiosum e. Bug bites Answer Molluscum contagiosum (answer d) is characterized by skin-coloured, 2 mm to 6 mm in size, discrete, dome-shaped papules with a central umbilication that may appear on any area of the body. Larger lesions As molluscum is usually self-limited and heals may become erythematous and occasionally puru - without scarring, treatment is not always necessary. lent. There is sometimes dermatitis surrounding the There are many treatment options which include: lesions ( i.e. , molluscum dermatitis). Children with • manual extraction, atopic dermatitis and immunocompromised children • cryotherapy, tend to develop larger numbers of lesions (dozens to • application of cantharidin, hundreds). Any given lesion persists for about two to • podophyllin and similar preparations and four months and new lesions keep appearing for sev - • topical imiquimod. eral months or even years. Most cases resolve spon - Oral cimetidine is controversial, but may be a useful taneously in six to nine months. option in a child that cannot tolerate other modalities. Molluscum is caused by a highly contagious Curettage is discouraged as it may lead to scarring. poxvirus that possesses sophisticated mechanisms for evading the immune system. It is transmitted by person-to-person contact, as well as by fomites. Outbreaks can occur among children attending swim - Mike Kalisiak, MD, BSc, is a Senior Dermatology ming pools. Resident, University of Alberta, Edmonton, Alberta. 58 The Canadian Journal of CME / May 2008 DERM CASE Case 6 Rough Bumps A 15-year-old boy presents with minute, discrete, keratotic papules on his arm. The lesions are asymp - tomatic. The patient is otherwise in good health. What is your diagnosis? a. Keratosis pilaris b. Pityriasis rubra pilaris c. Lichen spinulosus d. Folliculitis Answer Keratosis pilaris (answer a) is characterized by the presence of minute, discrete, keratotic, follicular papules with