Allergo-Immuno-Derma

Question 1

Atopy is not a risk factor for anaphylaxis from ____ and ____

Answer 1

drug reactions or hymenoptera stings

Atopy is not generally thought to be a risk factor for anaphylaxis from drug reactions or Hymenoptera stings, but it is associated with radiocontrast sensitivity, exercise-induced anaphylaxis, idiopathic anaphylaxis, and allergy to foods or latex.

Question 2

Dose of epinephrine for anaphylaxis

Answer 2

Epinephrine 0.3-0.5 ml of 1:1000 concentration IM

Question 3

More favorable outcomes are seen in patients with anaphylaxis who are given epinephrine within the first ____ minutes

Answer 3

20

Question 4

If with persistent hypotension (anaphylactic shock): IV infusion of ___ mL epinephrine, diluted ______ at 5- to 10-min intervals

Answer 4

2.5 mL epinephrine, diluted 1:10,000, at 5- to 10-min intervals

Question 5

key effector cell in asthma and allergic rhinitis?

Answer 5

mast cells

Question 6

How do you differentiate SJS vs TEN

Answer 6

Extent of surface area involved

SJS – total body surface area of blistering and eventual detachment is <10%
SJS/TEN overlap – 10–30% epidermal detachment
TEN – >30 epidermal detachment

Question 7

Poor prognostic factors for SJS/TEN

Answer 7

Intestinal and upper respiratory tract involvement
older age
greater extent of epidermal detachment

Question 8

most common variety of psoriasis

Answer 8

plaque type

Question 9

most common cause of chronic urticaria

Answer 9

idiopathic

Question 10

Most important preventive strategy in px with prev hx of anaphylaxis

Answer 10

avoidance of trigger

Question 11

Key pathway for ADR based on immune pathway

I
II
III
IVa
IVb
IVc
IVD

Answer 11

I - IgE
II - IgG mediated cytotoxicity
III- Immune complex
IVa- T cell mediated macrophage inflammation
IVb- T cell mediated eosinophil inflammation
IVc- T cell mediated Tcell inflammation
IVd- T cell mediated neutrophil inflammation

mnemonic: may MEeTiNg at 4pm
macrophage-eosino-t cell-neutro

Question 12

Urticaria, angioedema and anaphylaxis are under what type of classification of adverse drug reaction

Answer 12

Type I

Question 13

Drug induced hemolysis and thrombocytopenia are under what type of classification of adverse drug reaction

Answer 13

Type II

Question 14

Vasculitis, Serum sickness, Drug induced lupus are under what type of classification of adverse drug reaction

Answer 14

Type III

Question 15

TST and Contact dermatitis are under what type of classification of adverse drug reaction

Answer 15

Type IVA

Question 16

DIHS and Morbiliform eruption are under what type of classification of adverse drug reaction

Answer 16

Type IVB

Question 17

SJS and TEN and morbiliform eruption are under what type of classification of adverse drug reaction

Answer 17

Type IVC

Question 18

AGEP is under what type of classification of adverse drug reaction

Answer 18

Type IVD

Question 19

Aspirin exacerbated respiratory illness has 3 clinical features which include

Answer 19

Asthma
Sinus dse with recurrent nasal polyps
Sensitivity to aspirin and other NSAIDs

Question 20

When treatment center that lacks access to recombinant C1NH, bradykinin 2 receptor antagonist, kallikrein inhibitor, what could be given for acute attacks of hereditary angioedema?

Answer 20

FFP

Question 21

Most potent APC of the immune system

Answer 21

dendritic cells

Question 22

% risk of atopic dermatitis for patients with both parents with AD

Answer 22

> 80%

One parent >50%

Question 23

Most common site affected by seborrheic dermatitis

Answer 23

scalp

Question 24

Number of weeks to classify urticaria and/or angioedema as chronic

Answer 24

> 6 weeks

Question 25

Type of urticaria which presents in response to a sustained stimulus such as a shoulder strap or belt, running (feet), or manual labor (hands).

Answer 25

Pressure urticaria

Question 26

Type of urticaria that is distinctive in that the pruritic wheals are of small size (1–2 mm) and are surrounded by a large area of erythema; attacks are precipitated by fever, a hot bath or shower, or exercise and are presumptively attributed to a rise in core body temperature.

Answer 26

Cholinergic urticaria

Question 27

Angioedema without urticaria can be idiopathic or due to the generation of bradykinin in the setting of ______ deficiency that may be inborn as an autosomal dominant mutation or may be acquired through the appearance of an autoantibody in the setting of malignancy or autoimmune disease

Answer 27

C1 inhibitor (C1INH)

Question 28

Urticarial eruptions are distinctly pruritic, may involve any area ofthe body from the scalp to the soles of the feet, and appear in crops of _ h duration, with old lesions fading as new ones appear.

Answer 28

12- to 36-h

Question 29

Urticarial lesions that last longer than 36 h, result in scarring, and are reported as painful and not pruritic warrant ____ to evaluate for cellular infiltration, nuclear debris, and fibrinoid necrosis of the venules consistent with urticarial vasculitis.

Answer 29

biopsy

Question 30

antifibrinolytic agent that may be used for preoperative prophylaxis of hereditary angioedema but is contraindicated in patients with thrombotic tendencies or arterial atherosclerosis.

Answer 30

ε-aminocaproic acid

Question 31

most effective drugs available for the relief of established rhinitis, seasonal or perennial, and are effective in relieving nasal congestion as well as ocular symptoms

Answer 31

Intranasal high-potency glucocorticoids

Their most frequent side effect is local irritation, with fungal overgrowth being a rare occurrence.

Question 32

In allergic rhinitis, the efficacy of SLIT is comparable to SCIT but only for the three allergen formulations currently available which include what?

Answer 32

dust mite, timothy/northern grasses, and short ragweed

Question 33

most common presentation of anaphylaxis (>90% of cases)

Answer 33

Cutaneous manifestation

Question 34

Example of delayed anaphylatic reaction

Answer 34

anaphylaxis to meats in alpha-gal–sensitized patients.

Question 35

In anaphylaxis, The most obvious serum biomarker to assay,_____ , has an extremely short half-life with a measurable time-window that expires <1 h from the onset of anaphylaxis.

Answer 35

histamine

Question 36

In anaphylaxis, A more practical and useful biomarker is ______ , which peaks 60–90 min after the onset of anaphylaxis and can be measured as long as 5 h after the onset of anaphylaxis

Answer 36

serum tryptase

Question 37

it is recommended that patients who suffer from anaphylaxis be placed in the ____ position before receiving epinephrine.

Answer 37

Supine

an upright or sitting posture may lead to “empty ventricle syndrome” in which there is insufficient venous return to the heart from sudden-onset hypotension secondary to intravascular volume depletion. Epinephrine can further accelerate empty ventricle syndrome due to its chronotropic effects.

Question 38

80% of children with _____ allergy remain sensitive for life

Answer 38

peanut

While most allergy to egg, milk, soy, and/or
wheat resolves spontaneously during childhood

Question 39

Most forms of the disease (mastocytosis) are characterized by somatic gain-of-function mutations in the _____ gene.

Answer 39

stem cell factor receptor (KIT)

Question 40

Systemic mastocytosis (SM) refers to involvement of a noncutaneous site usually _____

Answer 40

bone marrow

Question 41

Type of systemic mastocytosis that accounts for the majority of adult patients.

Answer 41

Indolent systemic mastocytosis

Question 42

Smoldering systemic mastocytosis (SSM) is characterized by high mast cell burden as evidenced by a bone marrow infiltration of > ___ % and a baseline serum tryptase > ___ ng/mL (B findings), but absence of systemic mastocytosis associated with clonal hematologic non–mast cell lineage disease (SM-AHNMD) or aggressive systemic mastocytosis (ASM)

Answer 42

> 30%
200 ng/mL

Question 43

the rarest form of systemic mastocytosis and is invariably fatal at present

Answer 43

Mast cell leukemia (MCL)

Question 44

The cutaneous lesions of Maculopapular cutaneous mastocytosis (MPCM) are reddish-brown macules, papules, or plaques that respond to trauma with urtication and erythema AKA ____ sign

Answer 44

Darier’s sign

Question 45

Serum levels of this aracidonic acid dervided product diretcly correlates with anaphylaxis severity

Answer 45

Platelet activating factor

Question 46

Mediator of anaphylaxis that causes hypotension and tachycardia when released in high concentration

Answer 46

Histamine

Question 47

Type of psoriasis frequently after URTI
with B-hemolytic streptococci

Answer 47

Eruptive/Guttate psoariasis

also most common in children

Question 48

What is the tx of choice for non pregnant px with pustular psoariasis

Answer 48

oral retinoid

Question 49

why should you avoid oral glucocorticoids in severe widespread psoriasis

Answer 49

risk of life- threatening pustular psoriasis when therapy is discontinued

Question 50

4 key elements of pathogenesis of acne vulgaris

Answer 50

1. Follicular epidermal hyperprofliferation
2. Excess sebum production
3. Inflammation
4. Presence and activity of Propionibacterium acnes

Question 51

Most common form of pemphigus

Answer 51

pemphigus vulgaris

Question 52

Autoantibodies for pemphigus vulgaris

Answer 52

desmoglein 3 and 1

Question 53

Prevalent allele in bullous pemphigoid

Answer 53

MHC Class II allele HLA-DQβ1*0301

Question 54

Autoantibodies for bullous pemphigoid

Answer 54

hemidesmosomes

Question 55

Type of urticaria precipitated by fever, a hot bath or shower, or exercise

Answer 55

Cholinergic

Question 56

contraindication for immunotherapy for allergy

Answer 56

significant cardiovascular disease or unstable asthma

Question 57

Appropriate regimen for radiocontrast allergy prophylaxis

Answer 57

Prednisone 0.5mg/kg, 1 tablet at 13hrs, 6 hrs, 1hr prior to CT scan.

Question 58

This syndrome is characterized by recurrent bacterial infections, eczema and bleeding from thrombocytopenia

Answer 58

Wiskott-Aldrich Syndrome

Question 59

What should be given to patients with systemic mastocytosis with ssx of malabsorption

Answer 59

systemic steroids

Question 60

most potent known vasoconstrictor

Answer 60

LTD4

Question 61

lipid mediator responsible for leukocyte-endothelial cell adhesion and subsequent directed migration

Answer 61

LTB4

Question 62

lipid mediator responsible for vascular leak and mediates the recruitment of eosinophils to the bronchial mucosa

Answer 62

LTE4

vascular leeeeeak
eeeeosinophils

Question 63

How do you differentiate urticaria vs angioedema

Answer 63

Question 64

known risk factors for ACE I related angioedema

Answer 64

Black race, organ transplant, female gender, smoking, increasing age

Question 65

Heridary angioedema is aFully penetrant, autosomal dominant disease due to a mutation in the _____ gene (C1INH)

Answer 65

SERPING1

Question 66

Bradykinin-mediated angioedema, whether caused by ACE inhibitors or by C1INH deficiency, is noteworthy for these characteristics (3)

Answer 66

> conspicuous absence of concomitant urticaria or pruritus
frequent involvement of the gastrointestinal tract
duration of symptoms >24 h

Question 67

Other tx options for urticaria unresponsive to systemic glucocorticoids

Answer 67

Hydroxychloroquine, Dapsone, Colchicine
-Added to the regimen after hydroxyzine and before or along with systemic glucocorticoids

Cyclosporine
-Chronic idiopathic urticaria that is severe and poorly responsive to other modalities and/or where glucocorticoids are a requirement

Question 68

Known predisposing risk factors for allergic rhinitis

Answer 68

Female sex, particulate air pollution exposure, maternal tobacco smoking

Question 69

What constitues Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s Triad

Answer 69

triad of asthma, rhinosinusitis, respiratory reactions to COX-1 inhibitors

Question 70

Atopic triad

Answer 70

Bronchial asthma, allergic rhinitis, atopic dermatitis

Question 71

Major criteria for atopic dermatitis

Answer 71

CHIP

Chronicity
History of atopy
Involvement of face and flexures
Pruritus

Question 72

Mutation associated with atopic dermatitis

Answer 72

filaggrin mutation

Question 73

Difference between irritant vs allergic contact dermatitis

Answer 73

See table

Allergic contact dermatitis also goes beyond area of exposure

Question 74

Common sites of involvement of psoriasis

Answer 74

Scalp, elbows, knees, hands, feet,
trunk and nails

Question 75

Phenomenon in psoriasis wherein Traumatized areas develop lesions

Answer 75

Koebner phenomenon

Question 76

Sign in psoriasis wherein there is Bleeding after scale is removed

Answer 76

Auspitz sign

Question 77

Organisms involved in dermatophytosis

Answer 77

Trichophyton
Microsporum spp
Epidermophyton

Question 78

Treatment for pemphigus vulgaris

Answer 78

Treatment: Systemic glucorticoids alone/ in
combination with other immunosuppressive
agents

rituximab; azathioprine, mycophenolate mofetil,
or cyclophosphamide

Tx resistant disease: Plasmapheresis and/ IVIg

Question 79

Treatment for bullous pemphigus

Answer 79

Local disease: Potent topical lucocorticoids

Extensive disease: Systemic Glucocorticoids alone/ with other adjuncts

Doxycycline, azathioprine, Mycophenolate mofetil, Rituximab

Question 80

Which is nikolsky positive Pemphigus vulgaris or bullous pemphigoid?

Answer 80

pemphigus vulgaris

Question 81

Risk factors for adverse drug reactions

Answer 81

Elderly patient
Patients with autoimmune disease
Hematopoietic stem cell transplant recipient
With acute EBV and HIV infection

Question 82

Most common type of drueg eruptions

Answer 82

morbiliform eruptions

Question 83

Common culprit drugs for drug induced hypersensitivity syndrome

Answer 83

Anticonvulsants, sulfonamides, allopurinol, minocycline

Question 84

Color of tinea capitis and Microsporum canis under Wood’s lamp

Answer 84

Yellow fluorescence

Question 85

What type of adverse drug reaction is a acute generalized exanthematous pustulosis?
a. Type IVa
b. Type IVb
c. Type IVc
d. Type IVd

Answer 85

d. Type IVd

Question 86

A 35/F consulted your clinic due to dandruff. On physical examination, there are demarcated papules with silvery scales on the scalp, onycholysis and punctate pitting of the nails. Which is TRUE regarding the clinical manifestations of this condition?

a. Skin lesions evolve quickly
b. Lesions are typically observed in the axilla, groin, navel, and submammary region
c. Disease may remit spontaneously.
d. Presence of infection aggravates skin lesions

Answer 86

d. Presence of infection aggravates skin lesions

A. Skin lesions evolve quickly - indolent
B. Lesions are typically observed in the axilla, groin, navel, and submammary region – This is inverse psoriasis. Typical distribution is on the flexor surfaces usually.
C. Disease may remit spontaneously. - rarely
D. Presence of infection aggravates skin lesions

Question 87

Which represents the end stage of a variety of eczematous disorders?

a. Nummular Eczema
b. Lichen Planus
c. Lichen Simplex Chronicus
d. Asteatotic Eczema

Answer 87

c. Lichen Simplex Chronicus

Question 88

A 50/M consulted your clinic due to pruritic rash on his shins. On physical examination, there are circular scaly plaques on both pretibial areas. Which is an appropriate treatment for this case?
a. High-potency glucocorticoid
b. Cetirizine for pruritus
c. Emollient for dry areas
d. Use sulfur soap to clean the area

Answer 88

c. Emollient for dry areas

Diagnosis: Nummular eczema
Treatment is the same as atopic dermatitis.
A. High-potency glucocorticoid – low to mid-potency
B. Cetirizine for pruritus – sedating antihistamine
C. Emollient for dry areas
D. Use sulfur soap to clean the area – mild soap

Question 89

A 48/F consulted your clinic due to bipedal edema of 1 year duration. It is usually worse at the end of the day, after prolonged standing. On physical examination, you observed the presence of varicose veins, and brawny edema of the distal lower extremities with scaling and hyperpigmentation. Which is TRUE regarding the pathophysiology of this condition?
a. Typical initial site of involvement is the medial aspect of the ankle
b. Hyperpigmentation is due to the proliferation of subdermal fibrocytes
c. The brawny edema observed is due to hemosiderin deposition
d. Ulceration precedes the development of edema

Answer 89

a. Typical initial site of involvement is the medial aspect of the ankle

A. Typical initial site of involvement is the medial aspect of the ankle
B. Hyperpigmentation is due to the proliferation of subdermal fibrocytes – hemosiderin deposition
C. The brawny edema observed is due to hemosiderin deposition – dermal fibrosis
D. Ulceration precedes the development of edema – stasis dermatitis precedes ulceration

Question 90

A 45/F consulted your clinic due to dandruff. On physical examination you noted erythematous patches on the nasolabial fold, scalp, and eyebrows. What is the first line agent?
a. Clobetasol
b. Ciclopirox
c. Urea lotion
d. Tacrolimus

Answer 90

b. Ciclopirox

Diagnosis: Seborrheic dermatitis
A. Clobetasol
B. Ciclopirox – an antifungal
C. Urea lotion
D. Tacrolimus

Question 91

A 50/M just returned from a winter vacation in Hokkaido, Japan and is consulting for burning and itchy sensation on both shins. On physical examination you observed dry, cracked skin in the pretibial area with some scaling. What is the diagnosis?
a. Asteatotic Eczema
b. Atopic Dermatitis
c. Lichen Simplex Chronicus
d. Nummular Eczema

Answer 91

A. Asteatotic Eczema – dry skin exacerbated by the dry, cold weather

Question 92

A 48/F consulted your clinic due to cracked skin on her hands. She works as a laundrywoman and cleaner. On physical examination, you observed vesicles on the palms and lateral aspects of her fingers, some of which had erythematous bases and purulent discharge. Which of the following is an appropriate management for this case?
a. Advise patient to use latex gloves whenever her hands are exposed to water, detergents, and harsh chemicals.
b. Hot moist compress should be applied to the lesions.
c. Mid- to high-potency glucocorticoid ointment
d. Empiric coverage for dermatophyte infection.

Answer 92

c. Mid- to high-potency glucocorticoid ointment

A. Advise patient to use latex gloves whenever her hands are exposed to water, detergents, and harsh chemicals. - vinyl
B. Hot moist compress should be applied to the lesions. – cold moist
C. Mid- to high-potency glucocorticoid ointment
D. Empiric coverage for dermatophyte infection. - bacterial The correct answer is: Mid- to high-potency glucocorticoid ointment

Question 93

A 50/M consulted your clinic due to an erythematous plaque on his hypogastric area (from his belt buckle). What is your diagnosis?
a. Psoriasis
b. Lichen simplex chronicus
c. Irritant Contact Dermatitis
D. Allergic Contact Dermatitis

Answer 93

D. Allergic Contact Dermatitis

Question 94

How many grams of a topical agent is required to cover the entire body surface of an average adult?
a. 20 g
b. 30 g
c. 40 g
d. 50 g

Answer 94

b. 30 g

Question 95

A patient is on pimecrolimus cream for atopic dermatitis. Which of the following is a side effect of this medication?
a. Lymphoma
b. Adrenal insufficiency
c. Skin atrophy
d. Rosacea

Answer 95

a. Lymphoma

B. Adrenal insufficiency – topical glucocorticoid
C. Skin atrophy – topical glucocorticoid
D. Rosacea – topical glucocorticoid

Question 96

A 20/F consulted your clinic due to pruritic plaques on both popliteal fossae for the past 6 months. On physical examination, you observed xerotic skin and lichenified plaques on both popliteal fossae. Which of the following is an appropriate treatment to give?
a. High-potency topical glucocorticoid
b. Cetirizine
c. Tacrolimus ointment
d. Clindamycin

Answer 96

c. Tacrolimus ointment

A. High-potency topical glucocorticoid – NOT recommended for intertriginous areas
B. Cetirizine – non-sedating antihistamines are of little use in controlling pruritus of AD
C. Tacrolimus ointment – non-glucocorticoid anti-inflammatory that may be used in intertriginous areas D. Clindamycin – appropriate IF secondary infection is present

Question 97

What is the typical histologic pattern of eczema?
a. Presence of melanocytic segments
b. Inflammatory cell infiltration of the dermis
c. Dermal fibrosis
d. Spongiosis

Answer 97

d. Spongiosis

Question 98

Which cancer is associated with paraneoplastic pemphigus?

a. Acute myelocytic leukemia
b. Small cell lung cancer
c. Non-Hodgkin’s lymphoma
d. Papillary thyroid cancer

Answer 98

c. Non-Hodgkin’s lymphoma

Question 99

A 70/M consulted due to a papule on his face. Physical examination showed a large dome-shaped with a central keratotic crater. What is the diagnosis?
a. Actinic keratosis
b. Basal cell cancer
c. Melanoma
d. Squamous cell cancer

Answer 99

d. Squamous cell cancer

the lesion being described is a keratoacanthoma

Question 100

A 65/M was diagnosed with superficial basal cell carcinoma. What is the treatment of choice for this patient?
a. Wide excision
b. Electrodessication and curettage
c. Sonidegib
d. Laser therapy

Answer 100

b. Electrodessication and curettage

A. Wide excision – for invasive, ill-defined and aggressive tumors
B. Electrodessication and curettage – most commonly employed method
C. Sonidegib – metastatic or advanced BCC
D. Laser therapy

Question 101

Most common histologic subtype of malignant melanoma?
a. Lentigo maligna
b. Superficial spreading
c. Nodular
d. Acral lentiginous

Answer 101

b. Superficial spreading

Question 102

A 50/M consulted due to an enlarging mole on his nose. He is worried that it might be cancerous as his father was diagnosed with melanoma at age 60. Which is TRUE regarding risk factors for skin cancer?
a. First-degree relatives have a threefold risk of developing melanoma than those without a family history.
b. Majority of melanomas are familial.
c. The actual risk of transformation of nevus into melanoma is high
d. The presence of multiple nevi is one of the strongest risk factors

Answer 102

d. The presence of multiple nevi is one of the strongest risk factors

A. First-degree relatives have a threefold risk of developing melanoma than those without a family history. – twofold
B. Majority of melanomas are familial. – only 5-10% are truly familial
C. The actual risk of transformation of nevus into melanoma is high - LOW
D. The presence of multiple nevi is one of the strongest risk factors

Question 103

Most common dermatologic problem in patients with HIV infection?

a. Seborrheic dermatitis
b. Folliculitis
c. Ichthyosis
d. Reactivation herpes zoster

Answer 103

a. Seborrheic dermatitis

A. Seborrheic dermatitis – occurs up to 50% of patients with HIV
B. Folliculitis – 20%
C. Ichthyosis – not increased in frequency, but if present may be severe
D. Reactivation herpes zoster – 10-20%

Question 104

A 75/M was referred due to bullae formation on the trunk. On physical examination, there are tense vesicles & bullae on the trunk with erythematous urticarial bases. The lesions are non-pruritic and there are no oral lesions. What is the diagnosis?
a. Pemphigus vulgaris
b. Bullous pemphigoid
c. Pemphigus foliaceus
d. Epidermolysis bullosa acquisita

Answer 104

b. Bullous pemphigoid

A. Pemphigus vulgaris – has mucosal involvement
B. Bullous pemphigoid
C. Pemphigus foliaceus – crusts & shallow erosions on scalp, central face, upper chest, and back
D. Epidermolysis bullosa acquisita – blisters, erosions, scars, and milia on sites exposed to trauma; widespread; tense blisters may be seen initially

Question 105

Which of the following is a skin biopsy finding in discoid lupus erythematosus?
a. Acantholysis in suprabasal epidermis
b. Sparse infiltrate of mononuclear cells in the dermis
c. Hydropic degeneration of basal keratinocytes
d. Epidermal atrophy

Answer 105

d. Epidermal atrophy

A. Acantholysis in suprabasal epidermis – pemphigus vulgaris
B. Sparse infiltrate of mononuclear cells in the dermis – acute cutaneous lupus
C. Hydropic degeneration of basal keratinocytes – acute cutaneous lupus
D. Epidermal atrophy – chronic/discoid lupus

Question 106

Which of the following cutaneous manifestations are seen in ACUTE cutaneous lupus?
a. Evanescent erythema of upper chest
b. Psoriasiform eruption on chest and back
c. Discoid rash
d. Papulosquamous eruption on extensor surfaces

Answer 106

a. Evanescent erythema of upper chest

A. Evanescent erythema of upper chest
B. Psoriasiform eruption on chest and back - subacute C. Discoid rash - chronic
D. Papulosquamous eruption on extensor surfaces - subacute

Question 107

Which skin finding is seen in dermatomyositis but is rare in lupus and scleroderma?
a. Raynaud’s phenomenon
b. Poikiloderma
c. Malar rash
d. Sclerodactyly

Answer 107

b. Poikiloderma - areas of hypopigmentation, hyperpigmentation, mild atrophy, and telangiectasia

The rest of the findings may be seen in SLE, Scleroderma or overlap syndromes.

Question 108

A 25/M consulted due to fever. On physical examination, there are palpable nonblanching purpura on the lower extremities. Which is the LEAST likely differential?
a. Staphylococcal scalded skin syndrome
b. Ecthyma gangrenosum
c. Henoch-Schonlein purpura
d. Meningococcemia

Answer 108

a. Staphylococcal scalded skin syndrome

Diagnosis is meningococcemia
A. Staphylococcal scalded skin syndrome - only one that presents as bullae & not purpura
B. Ecthyma gangrenosum
C. Henoch-Schonlein purpura
D. Meningococcemia

Question 109

A 38/F consulted due to hypopigmented patches on her face and hands. What is the disorder that is most frequently associated with this condition?
a. Addison’s disease
b. Type 1 Diabetes Mellitus
c. Hashimoto’s Thyroiditis
d. Pernicious anemia

Answer 109

c. Hashimoto’s Thyroiditis

Question 110

A 30/F consulted due to red rash on her face and hands. On physical examination, there are oval macules less than 1 cm, which on closer inspection turned out to be telangiectasias. This patient needs to be worked up for what disease?
a. Hereditary hemorrhagic telangienctasia
b. Dermatomyositis
c. Systemic Lupus Erythematosus
d. Scleroderma

Answer 110

d. Scleroderma

remember cresT syndrome

Mat telangiectasia commonly seen in face, oral mucosa and hands

Question 111

Which drug can cause anagen effluvium?

a. Colchicine
b. Daunorubicin
c. Warfarin
d. Lithium

Answer 111

b. Daunorubicin

The rest cause diffuse hair loss, usually by inducing a telogen effluvium

Question 112

A 35/F was admitted due to fever and cough. She has a history of being treated for eczema of the knees and elbows. On physical examination, you observed generalized skin erythema with some areas studded with pustules. What is the diagnosis?

a. Exfoliative dermatitis
b. Pityriasis rubra pilaris
c. Pustular psoriasis
d. Sezary syndrome

Answer 112

c. Pustular psoriasis

History of eczema on knees and elbows points to psoriasis.
The presence of concomitant infection triggered the erythroderma.

Question 113

A 48/F consulted your clinic due to scaly plaques of 6 months duration. She was previously told she had eczema and was prescribed topical steroids but her lesions failed to improve. Skin biopsy of the lesion showed atypical lymphocytes in the epidermis and dermis. What is the diagnosis?

a. Bowen’s Disease
b. Lichen Planus
c. Mycosis Fungoides
d. Psoriasis

Answer 113

c. Mycosis Fungoides

Question 114

Most common malignancy associated with erythroderma?

a. Cutaneous T Cell Lymphoma
b. Non-Small Cell Lung Cancer
c. HTLV-1 Associated Adult T Cell Leukemia
d. Hodgkin’s Lymphoma

Answer 114

a. Cutaneous T Cell Lymphoma

There have been isolated case reports of erythroderma secondary to some solid tumors—lung, liver, prostate, thyroid, and colon

Question 115

A 40/M consulted your clinic due to pruritic papules and plaques on his wrist (multiple flat-topped, violaceous papules and plaques). On physical examination, you also observed nail dystrophy.

What is your diagnosis?

a. Lichen planus
b. Psoriasis
c. Pityriasis Rosea
d. Dermatophytosis

Answer 115

a. Lichen planus

Question 116

A 35/F has psoriasis and arthritis and was advised to start systemic therapy. The patient has not been compliant with previous medications as she kept forgetting to take them. Which medication would be appropriate to give to her?

a. Methotrexate
b. Acitrecin
c. Cyclosporine
d. Apremilast

Answer 116

a. Methotrexate

A. Methotrexate – the only one among the choices that is dosed once weekly making it better for compliance

Question 117

A 32/F has psoriasis, spondylitis & arthritis. Which biologic agent is efficacious for both conditions?

a. Certolizumab pegol
b. Golimumab
c. Ixekizumab
d. Secukinumab

Answer 117

d. Secukinumab

A. Certolizumab pegol – Psoriatic arthritis (PsA)
B. Golimumab – Psoriatic arthritis (PsA)
C. Ixekizumab – Psoriasis (Ps)

Question 118

A 25/F has a solitary silvery plaque on her right elbow. There are no other skin lesions nor nail changes on physical examination. Which is an appropriate treatment to give?

a. Anthralin
b. Coal Tar
c. Calcipotriene
d. Salicylic Acid

Answer 118

c. Calcipotriene

Diagnosis: Limited Psoriasis
A. Anthralin
B. Coal Tar
C. Calcipotriene – topical Vitamin D analogue which has replaced these other choices for limited psoriasis
D. Salicylic Acid

Question 119

Which of the following treatments for psoriasis is correctly matched with the adverse effect?

a. Tazarotene – skin cancer
b. Oral glucocorticoid – pustular psoriasis
c. Apremilast – teratogenicity
d. Acitrecin – pancytopenia

Answer 119

b. Oral glucocorticoid – pustular psoriasis

A. Tazarotene – skin cancer (Psoralens are the ones which predisposes to skin cancer. Tazarotene is a topical retinoid)
B. Oral glucocorticoid – pustular psoriasis
C. Apremilast – teratogenicity (Hypersensitivity, GI symptoms)
D. Acitrecin – pancytopenia (Teratogenicity, as it is a retinoid)

Question 120

A 28/M has erythematous scaly plaques on both knees and elbows. On physical examination, you observed sausage digits. What other disease will he need to be screened for?

a. Diabetes
b. Hepatitis A
c. Bronchial asthma
d. Colon cancer

Answer 120

a. Diabetes

Diagnosis is plaque-type psoriasis with psoriatic arthritis. Given increased risk of metabolic syndrome, he needs to be screened for diabetes.

In case he would need immunosuppressive therapy, he will also need to be screened for TB, HIV, and Hepatitis B or C.

Question 121

Oral oral antifungal agents are often used in which type of dermatophyte infection?

a. Tinea cruris
b. Tinea pedis
c. Tinea capitis
d. Tinea corporis

Answer 121

c. Tinea capitis

For dermatophyte infections involving the hair and nails and for other infections unresponsive to topical therapy, oral antifungal agents are often used
Topical therapy is generally effective for uncomplicated tinea corporis, tinea cruris, and limited tinea pedis

Question 122

Which of the agents used to treat leprosy is bactericidal?

a. Dapsone
b. Clofazimine
c. Streptomycin
d. Rifampin

Answer 122

d. Rifampin

Question 123

Key immune mediators in SJS/TEN:

a. IgE
b. Eosinophils
c. IL-4, IL-5 and IL-13
d. Granulysin

Answer 123

d. Granulysin

Question 124

Causes drug-induced lipofuscinosis with characteristic red-brown coloration

a. Clofazimine
b. Minocycline
c. Quinacrine
d. Bismuth

Answer 124

a. Clofazimine

• Blue gray pigmentation: long term minocycline and amiodarone, pefloxacin
• Gray-brown pigmentation: phenothiazine, gold, bismuth
• Red-brown coloration: clofazimine
• Yellow discoloration: quinacrine

Question 125

True of fixed drug eruptions:

a. Hyperpigmentation often results after resolution of acute inflammation
b. With rechallenge, the process recurs a different location
c. Lesions often involve the scalp
d. Most patients have a single lesion

Answer 125

a. Hyperpigmentation often results after resolution of acute inflammation

One or more sharply demarcated, dull red to brown lesions, sometimes with central dusky violaceous erythema and central bulla

Hyperpigmentation often results after resolution of the acute inflammation

With rechallenge, the process recurs in the same (fixed) location but may spread to new areas as well
Lesions often involve the lips, hands, legs, face, genitalia, and oral mucosa, and cause a burning sensation

Most patients have multiple lesions

Fixed drug eruptions have been associated with pseudoephedrine (frequently a nonpigmenting reaction), phenolphthalein (in laxatives), sulfonamides, tetracyclines, NSAIDs, barbiturate

Question 126

A 50/F was referred for evaluation of purpuric papules and macules involving the lower extremities. Further work up showed elevated creatinine. Cutaneous small vessel vasculitis was considered. This finding on skin biopsy can be a clue to possible drug etiology:

a. Presence of perivascular eosinophils
b. Nonspecific inflammatory changes
c. Collections of neutrophils and sparse necrotic keratinocytes in the upper part of the epidermis
d. Full thickness epidermal necrosis

Answer 126

a. Presence of perivascular eosinophils

Presents with purpuric papules and macules involving the lower extremities and other dependent areas

May involve other organs, including the kidneys, joints, gastrointestinal tract, and lungs, necessitating a thorough clinical evaluation for systemic involvement

Drugs are implicated as a cause of roughly 15% of all cases of small vessel vasculitis

May also be idiopathic or due to underlying infection, connective tissue disease, or (rarely) malignancy

Presence of perivascular eosinophils on skin biopsy can be a clue to possible drug etiology.

Question 127

Drug associated with pemphigus:

a. Furosemide
b. Vancomycin
c. Terbinafine
d. D-penicillamine

Answer 127

d. D-penicillamine

New onset SLE: IL-2, IFN-α, and anti-TNF-α
Granulomatous disease and sarcoidosis: IFN and TNF-inhibitors
Pemphigus: D-penicillamine and ACE inhibitors
Bullous pemphigoid: furosemide and PD-1 inhibitors
Linear IgA bullous dermatosis: vancomycin
Nephrogenic systemic fibrosis: gadolinium contrast
Neutrophilic dermatoses: GCSF, azacitidine, ATRA and the FLT3- inhibitor class of drug

Question 128

True of urticaria:

a. Most frequent type of cutaneous reaction to drugs
b. Characterized by blanching erythematous macules and papules
c. May be caused by an IgE-dependent mechanism, circulating immune complexes, or nonimmunologic activation of effector pathways
d. Rechallenge may be done in an outpatient setting

Answer 128

c. May be caused by an IgE-dependent mechanism, circulating immune complexes, or nonimmunologic activation of effector pathways

Second most frequent type of cutaneous reaction to drugs
Characterized by pruritic, red wheals of varying size rarely lasting more than 24 hours
Observed in association with nearly all drugs, most frequently ACE inhibitors, aspirin, NSAIDs, penicillin, and blood products
Drug-induced urticaria may be caused by three mechanisms: an IgE-dependent mechanism, circulating immune complexes (serum sickness), and nonimmunologic activation of effector pathways
Future drug avoidance is recommended
Rechallenge, especially in individuals with severe reactions, should only occur in an intensive care setting

Question 129

True of furunculosis:

a. Caused by Group A Streptococcus
b. Characterized by annular scaly plaques
c. Family members or close contacts may also be affected
d. Treatment include topical selenium sulfide lotion or azoles

Answer 129

c. Family members or close contacts may also be affected

Caused by S. aureus, and this disorder has gained prominence in the last decade because of CA-MRSA

Painful, erythematous nodule that can occur on any cutaneous surface

Family members or close contacts may also be affected

Furuncles can rupture and drain spontaneously or may need incision and drainage, which may be adequate therapy for small solitary furuncles without cellulitis or systemic symptoms

Whenever possible, lesional material should be sent for culture

Current recommendations for methicillin-sensitive infections are β-lactam antibiotics
Warm compresses and nasal mupirocin are helpful therapeutic additions
Severe infections may require IV antibiotic

Question 130

A 34/F was referred due to multiple warts on the face and neck. PE showed multiple sessile, dome-shaped lesions. The most useful and convenient method for treating warts in almost any location is:

a. Salicylic acid plasters or solutions
b. Cryotherapy with liquid nitrogen
c. Podophyllin solution
d. Topical imiquimod

Answer 130

b. Cryotherapy with liquid nitrogen

Caused by papillomaviruses
Filiform warts are most commonly seen on the face, neck, and skinfolds

Cryotherapy with liquid nitrogen: most useful and convenient method for treating warts in almost any location

Question 131

Which of the following statement is correct regarding use of isotretinoin in patients with acne vulgaris?

a. Dose is based on patient’s weight
b. Isotretinoin is given twice daily for 5 months
c. Its use is highly regulated due to its potential for severe adverse events, primarily teratogenicity and anxiety
d. All female patients should have two negative pregnancy tests prior to each refill

Answer 131

a. Dose is based on patient’s weight

Patients with severe nodulocystic acne unresponsive to the therapies discussed above may benefit from treatment with the synthetic retinoid isotretinoin

Its dose is based on the patient’s weight, and it is given once daily for 5 months

Its use is highly regulated due to its potential for severe adverse events, primarily teratogenicity and depression

All female patients have two negative pregnancy tests prior to initiation of therapy and a negative pregnancy test prior to each refill

Isotretinioin causes hyperTAG

Question 132

A 68/M with metastatic non-small cell lung cancer developed rash, pruritus and vitiliginous depigmentation after initiation of therapy. Which medication is responsible for this reaction?

a. Sorafenib
b. Erlotinib
c. Ipilimumab
d. Capecitabine

Answer 132

c. Ipilimumab

Acral erythema: cytarabine, doxorubicin, methotrexate, hydroxyurea, fluorouracil, and capecitabine

Hair textural changes: erlotinib

Follicular eruptions and focal bullous eruptions at palmoplantar, flexural sites or areas of frictional pressure: sorafenib

Rash, pruritus, and vitiliginous depigmentation: ipilimumab

Question 133

A 60/F, known hypertensive on amlodipine 10mg OD, was referred for evaluation of rash. On PE, patient was highly febrile, with innumerable pinpoint pustules with underlying erythema. Lesions are most pronounced in the antecubital area. Which statement is true regarding this condition?

a. Erosions tend to be deep and prominently involve the mucosa
b. Skin biopsy shows full thickness epidermal necrosis
c. Principal differential diagnosis is erythema multiforme
d. Patch testing with the responsible drug often results in a localized pustular eruption

Answer 133

d. Patch testing with the responsible drug often results in a localized pustular eruption

Patients typically present with diffuse erythema or erythroderma, as well as high spiking fevers, and leukocytosisOne to two days later, innumerable pinpoint pustules develop overlying the erythema
Pustules are most pronounced in body fold areas; however, they may become generalized and, when coalescent, can lead to superficial erosion

Erosions tend to be more superficial, and prominent mucosal involvement is lacking

Skin biopsy shows collections of neutrophils and sparse necrotic keratinocytes in the upper part of the epidermis

The principal differential diagnosis for AGEP is acute pustular psoriasis, which has an identical clinical and histologic appearance

β-Lactam antibiotics, calcium channel blockers, macrolide antibiotics, and other inciting agents (including radiocontrast and dialysates) have been reported

Patch testing with the responsible drug often results in a localized pustular eruption

Question 134

A 44-year-old female consulted due to fever and flu-like symptoms for 3 days followed by appearance of diffuse morbilliform rash involving the face. She was diagnosed to have hypertension and hyperuricemia 6 weeks ago and was prescribed amlodipine and allopurinol, which she took with good compliance. On PE, patient was hypotensive. You noted fever, icteric sclerae, cervical and inguinal lymphadenopathies and hepatomegaly. CBC showed mild eosinophilia and atypical lymphocytes. Which statement is correct?

a. Mycophenolate mofetil should be started
b. Patient should be closely monitored for development of early-onset autoimmune thyroiditis
c. Patient should undergo cardiac evaluation
d. Most fatalities result from heart failure

Answer 134

c. Patient should undergo cardiac evaluation

Mortality rates as high as 10% have been reported, with most fatalities resulting from liver failure

Systemic glucocorticoids (1.5–2 mg/kg/d prednisone equivalent) should be started and tapered slowly over 8–12 weeks, during which time clinical symptoms and labs (including complete blood count with differential, basic metabolic panel, and liver function tests) should be followed carefully

A steroid-sparing agent such as mycophenolate mofetil may be indicated in cases of rapid recurrence upon steroid taper

Given the severe long-term complications of myocarditis, patients should undergo cardiac evaluation in cases of severe DIHS or if heart involvement is suspected due to hypotension or arrhythmia
Patients should be closely monitored for resolution of organ dysfunction and for development of late-onset autoimmune thyroiditis and diabetes (up to 6 months)

Question 135

A 23/M PLHIV developed morbilliform eruption in response to prior sulfonamide exposure. What will be your recommendation?

a. Skin prick testing
b. Patch testing
c. Intradermal testing
d. Desensitization

Answer 135

d. Desensitization

• Skin-prick testing
  o In patients with a history suggesting immediate IgE-mediated reactions to penicillin, skin-prick testing with penicillins or cephalosporins has proven useful for identifying patients at risk of anaphylactic reactions to these agents
  o Negative skin tests do not totally rule out IgE-mediated reactivity
   Risk of anaphylaxis in response to penicillin administration in patients with negative skin tests is about 1%

Desensitization
o Considered in those with a history of reaction to a medication that must be used again
o Efficacy of such procedures has been demonstrated in cases of immediate reaction to penicillin and positive skin tests, anaphylactic reactions to platinum chemotherapy, and delayed reactions to sulfonamides in patients with AIDS
o Often successful in HIV-infected patients with morbilliform eruptions to sulfonamides but is not recommended in HIV-infected patients who developed erythroderma or a bullous reaction in response to prior sulfonamide exposure

Question 136

A 44-year-old female consulted due to fever and flu-like symptoms for 3 days followed by appearance of diffuse morbilliform rash involving the face. She was diagnosed to have hypertension and hyperuricemia 6 weeks ago and was prescribed amlodipine and allopurinol, which she took with good compliance. On PE, you noted fever, icteric sclerae, cervical and inguinal lymphadenopathies and hepatomegaly. CBC showed mild eosinophilia and atypical lymphocytes. What is true about this condition?

a. Reactivation of herpesvirus 6 and Epstein-Barr virus (EBV) has been frequently reported in this syndrome
b. Mucosal erosions are frequent, usually at 2 or more sites
c. Skin biopsy showing full thickness epidermal necrosis in the absence of substantial dermal inflammation is consistent with the diagnosis
d. Patch testing the suspect drug would result in a localized pustular eruption

Answer 136

a. Reactivation of herpesvirus 6 and Epstein-Barr virus (EBV) has been frequently reported in this syndrome

DHIS
* Presents with a prodrome of fever and flu-like symptoms for several days, followed by the appearance of a diffuse morbilliform eruption usually involving the face
* Facial swelling and hand/foot swelling are often present
* Lymphadenopathy, fever, and leukocytosis (often with eosinophilia or atypical lymphocytosis)
* Hepatitis, nephritis, pneumonitis, myositis, and gastroenteritis (in descending order)
* Cutaneous reaction usually begins 2–8 weeks after the drug is started and persists after drug cessation
* Reactivation of herpes viruses, in particular human herpesviruses 6 and 7, EBV, and cytomegalovirus (CMV), has been frequently reported in this syndrome

Question 137

Predominant cause of Tinea capitis

Answer 137

Tinea tonsurans

Question 138

Px with erythema gyratum repens should be worked up for

Answer 138

underlying malignancy

Question 139

Erythema migrans and marginatum are seen in

Answer 139

migrans: Lyme dse
marginatum Acute rheumatic fever

Question 140

Nailfold telangiectesias are pathognomonic signs of 3 major autoimmune CTD which include

Answer 140

SLE
Systemic sclerosis
Dermatomyositis

Question 141

What is Leser Trelat sign

Answer 141

Sudden appearance of multiple lesions often with an inflammatory base with acrochordons + acanthosis nigricans

Work up for internal malignancy

Question 142

SSS is caused by this enzyme secreted by S. aureus

Answer 142

Exfoliatin

Question 143

Genetic polymorphism associated with
Abacavir
Carbamazepine
Allopurinol

Answer 143

Abacavir = HLA B57:01
Carbamazepine = HLA B15:02
Allopurinol = HLA B*58:01

Question 144

Onycholysis vs Onychomadesis

Answer 144

Onycholysis- detachment of distal part of nail
Onymadesis- detachment of proximal part of nail

Question 145

HIV -1 infections are mostly from group

Answer 145

Group M subtype C

Question 146

Chief predictor of heterosexual transmission in HIV

Answer 146

Level of plasma viremia

Question 147

Blood products/ blood related products not associated with HIV transmission

Answer 147

HyperIg
HbIg
Plasma derived Hep b vaccine
Rho Immune globulin

Question 148

Antibodies to HIV generally appear in the circulation ____ weeks following infection

Answer 148

3-12 weeks

Question 149

Negative screening for HIV -1 and 2 should warrant retesting after ____ months if clinically indicated

Answer 149

3-6

Question 150

Indeterminate HIV western blot result would warrant repeat testing after ______

Answer 150

4-6 weeks

A stable indeterminate western blot after 4-6 weeks makes HIV infection unlikely. However, it should be repeated twice in 3 month intervals to r/o HIV infection

Question 151

T/F Positive 4th gen asssay for HIV confirmed by second HIV1 or 2 specific immunoassay or plasma HIV RNA is adequate for dx

Answer 151

True

Western blot is no longer used for this purpose

Question 152

Best indicator of immunologic competence in PLHIV

Answer 152

CD4 count

Question 153

Prophylaxis indicated when CD4 count is
<50
<200

Answer 153

< 50 MAC
<200 PCP

CD4 measurements should be performed at the time of diagnosis and 3-6 months thereafter but optional for px on ART for at least 2 yrs and HIV RNA <50 and CD4 >500

Question 154

A 32/F with Protein C deficiency on 7th day of warfarin anticoagulation was referred due to a sharply demarcated, purpuric lesion with hemorrhagic bullae and eschar formation. How will you manage the patient?

a. Fluid management, atraumatic wound care, prednisone 1-2mg/kg
b. Epinephrine and intravenous glucocorticoids
c. Vitamin K, heparin, surgical debridement and intensive wound care
d. Oral antihistamine and emollients

Answer 154

c. Vitamin K, heparin, surgical debridement and intensive wound care

Common sites: breasts, thighs, and buttocks
* Sharply demarcated, erythematous, or purpuric, and may progress to form large, hemorrhagic bullae with necrosis and eschar formation
* Rare reaction (0.01–0.1%)
* Usually occurs between the third and tenth days of therapy with warfarin
* Usually in women
* Treated with vitamin K, heparin, surgical debridement, and intensive wound care
* Treatment with protein C concentrates may also be helpful.
* Newer anticoagulants such as dabigatran etexilate may avoid warfarin necrosis in high-risk patients

Question 155

A 48/F started treatment for leprosy 6 months ago. She is currently consulting due to the appearance of painful papules on her arms associated with fever. What type of reactional state is the patient experiencing?

a. Type 1 lepra downgrading
b. Type 1 lepra reversal
c. Type 2 lepra
d. Lucio’s phenomenon

Answer 155

c. Type 2 lepra

A. Type 1 lepra downgrading – inflammation of lesions PRIOR to tx
B. Type 1 lepra reversal – inflammation of lesions AFTER initiation of tx
C. Type 2 lepra – diagnosis is erythema nodosum leprosum
D. Lucio’s phenomenon – recurrent crops of ulcerative lesions

Question 156

A 50/F consulted due to skin nodules. On physical examination, there is loss of eyebrows, dry skin, symmetric nodular lesions, palpable ulnar nerve, and claw hand deformity. What is the classification of her leprosy?

a. Tuberculoid
b. Borderline Tuberculoid
c. Borderline Lepromatous
d. Lepromatous

Answer 156

d. Lepromatous

Question 157

Which of the following is indication for oral antifungal treatment?

a. Uncomplicated tinea corporis
b. Tinea cruris
c. Limited tinea pedis
d. Hair and nail infection

Answer 157

d. Hair and nail infection

Question 158

TNF inhibitors have been associated with which of the following conditions?

a. Amyloidosis
b. Bullous pemphigoid
c. Extensive seborrhea
d. Granulomatous diseases and sarcoidosis

Answer 158

d. Granulomatous diseases and sarcoidosis

Question 159

Which of the following indicate severe cutaneous drug reaction?

a. Basophilia
b. Fever
c. Lymphocytopenia
d. Petechial rash

Answer 159

b. Fever

Question 160

Contact dermatitis is considered a Type IVa adverse drug reaction. What is the key pathway involved in this reaction?

a. IgE
b. IgG-mediated toxicity
c. Immune complex
d. T lymphocyte-mediated macrophage inflammation

Answer 160

d. T lymphocyte-mediated macrophage inflammation

Question 161

Gastrointestinal involvement in a Drug-induced Hypersensitivity Syndrome (DIHS) is almost exclusively seen in patients who use the following drug:

a. Minocycline
b. Allopurinol
c. Abacavir
d. Lamotrigine

Answer 161

c. Abacavir

Allopurinol classically induces DIHS with renal involvement (AllopuRENAL)

Cardiac and lung involvements are more common with minocycline

Gastrointestinal involvement is almost exclusively seen with abacavir (aBAKAvir–> Baka is kinakain –> GI)

Question 162

True of scabies:

a. The etiologic agent is Pediculus humanus
b. Gravid female mites (~0.3 mm in length) burrow within the stratum basale, depositing several eggs per day
c. Newly fertilized female mites are transferred from person to person mainly by direct skin-to-skin contact
d. Scabies mites continue to live even in the absence of a suitable host.

Answer 162

c. Newly fertilized female mites are transferred from person to person mainly by direct skin-to-skin contact

Etiologic agent: Sarcoptes scabiei var. hominis

Gravid female mites (~0.3 mm in length) burrow superficially within the stratum corneum, depositing several eggs per day

Newly fertilized female mites are transferred from person to person mainly by direct skin-to-skin contact
Transfer is facilitated by crowding, poor hygiene, and sex with multiple partners

Generally, scabies mites die within a day or so in the absence of a suitable host

Transmission via sharing of contaminated bedding or clothing occurs less frequently than is often thought

Question 163

A 23/F consulted due to nocturnal pruritus. On PE, small papules and vesicles were seen along the volar wrists and digital web spaces. The following statements are correct except:

a. Permethrin cream (5%) is less toxic than 1% lindane preparations
b. Scabicides are applied thinly but thoroughly from the jawline down after bathing and removed 8-14 hours later with soap and water
c. Within 1 day of effective treatment, scabies infestations become noncommunicable.
d. Only symptomatic close contacts of confirmed cases should be treated.

Answer 163

d. Only symptomatic close contacts of confirmed cases should be treated.

Pruritus typically intensifies at night and after hot showers.

Scabetic lesions are most common on the volar wrists and along the digital web spaces

In males, the penis and scrotum become involved
Small papules and vesicles, often accompanied by eczematous plaques, pustules, or nodules, appear symmetrically at those sites and within intertriginous areas, around the navel and belt line, in the axillae, and on the buttocks and upper thighs

Permethrin cream (5%) is less toxic than 1% lindane preparations and is effective against lindane-tolerant infestations

Scabicides are applied thinly but thoroughly from the jawline down after bathing—with careful application to interdigital spaces and the umbilicus and under the fingernails—and are removed 8–14 h later with soap and water

Within 1 day of effective treatment, scabies infestations become non-communicable, but the pruritic hypersensitivity dermatitis induced by the dead mites and their remnant products frequently persists for weeks

To prevent reinfestations, bedding and clothing should be washed and dried on high heat or heat-pressed
Close contacts of confirmed cases, even if asymptomatic, should be treated simultaneously.

Question 164

True of head lice:

a. Transmitted mainly by fomites such as shared headgear, bed linens and grooming implements
b. Chronic infestations tend to be asymptomatic
c. Head lice are known to serve as a natural vector for any pathogens
d. Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb successfully eliminate infestations

Answer 164

b. Chronic infestations tend to be asymptomatic

Head lice are transmitted mainly by direct head-to-head contact rather than by fomites such as shared headgear, bed linens, and grooming implements

Chronic infestations by head lice tend to be asymptomatic

Head lice are not known to serve as a natural vector for any pathogens

Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations

Question 165

True regarding treatment of louse infestation:

a. Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations
b. Treatment of newly identified active infestations traditionally relies on a 10-min topical application of ~1% permethrin or pyrethrins, daily for a total of 10 days
c. Chronic infestations may be treated for ≤12 h with 0.5% permethrin
d. Lindane is applied for just 4 min and is most effective

Answer 165

a. Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations

Generally, treatment is justified only if live lice are discovered

The presence of nits alone is evidence of a former—not necessarily current—infestation

Mechanical removal of head lice and their eggs with a fine-toothed louse or nit comb often fails to eliminate infestations

Treatment of newly identified active infestations traditionally relies on a 10-min topical application of ~1% permethrin or pyrethrins, with a second application ~10 days later

Lice persisting after this treatment may be resistant to pyrethroids

Chronic infestations may be treated for ≤12 h with 0.5% malathion

Lindane is applied for just 4 min but seems less effective and may pose a greater risk of adverse reactions, particularly when misused.

Question 166

Transient, blanchable erythematous macules and papules, 2-4 mm, usually on trunk are seen in which of the following conditions?

a. Erythema multiforme
b. Erythema nodosum
c. Herpes simplex
d. Typhoid fever

Answer 166

d. Typhoid fever

Question 167

Erythema infectiosum presents in adult patients as arthritis, fever and rash. Which of the following is the etiologic agent for this condition?

a. Epstein-Barr virus
b. Human Herpes Virus 6
c. Human Parvovirus B19
d. Paramyxovirus

Answer 167

c. Human Parvovirus B19

Question 168

A 40 year old female complained of persistent facial flushing which started 1 month ago. The symptom worsened with alcohol intake, hot drinks and spicy foods. There were no other complaints. P.E findings revealed erythema, telangiectasia, scattered papules and small pustules that is more prominent on the cheeks and nose. What is your impression?
A. Acne rosacea
B. Pityriasis rosea
C. Seborrheic dermatitis
D. Hypersensitivity reaction

Answer 168

A. Acne rosacea

Question 169

A 23/F consults for slowly enlarging sharply demarcated erythematous plaques over both elbows, knees and scalp
areas. Histologic features from the skin biopsy of the lesion will typically show:
a. Interface dermatitis
b. Hyphae and neutrophils in stratum corneum
c. Eosinophils and lymphocytes in the dermis
d. Acanthosis and vascular proliferation

Answer 169

d. Acanthosis and vascular proliferation

This case is consistent with psoriasis, a chronic inflammatory skin condition characterized by sharply demarcated erythematous plaques with silvery-white scales that commonly affect extensor surfaces like the elbows and knees, as well as the scalp.

Question 170

29-year-old male soldier consulting for persistent nonpruritic, nonpainful, hyperpigmented patches on the trunk and back. KOH preparation demonstrates a confluence of “spaghetti and meatballs” configuration. What is the treatment of choice?
a. Ketoconazole 200mg/tab OD PO
b. Topical hydrocortisone TID
c. Topical selenium sulfide OD
d. Topical clotrimazole TID

Answer 170

c. Topical selenium sulfide OD

Question 171

32-year-old female consulting for very slowly healing vesicles and bullae that rupture, producing moist erosions with a hemorrhagic base with crusting and purplish discoloration over the dorsal hands, forearms and face especially when exposed to sunlight. She is a smoker with a regular alcohol intake. She has no known comorbidities. She denies illicit drug use and only takes self-prescribed ASA and OCPs. Initial test show negative ANA result. What is the next best step?
a. Determine plasma porphyrin
b. Perform skin biopsy
c. Order phototest with UVB and UVA
d. Discontinue ASA

Answer 171

a. Determine plasma porphyrin

This presentation is highly suggestive of porphyria cutanea tarda (PCT), a disorder of heme biosynthesis resulting in photosensitivity and skin fragility due to accumulation of porphyrins. The next best step is to determine plasma porphyrin levels to confirm the diagnosis

Alcohol intake, smoking, and estrogen use (oral contraceptives) are all known triggers for PCT.

Question 172

A 65-year-old hypertensive male presents with a generalized urticarial rash with pruritus and hypotension after undergoing whole abdominal CT Scan with contrast. He had been admitted for abdominal distension and is being worked up for mechanical bowel obstruction, probably due to a colonic mass. He claims to have no food and drug allergies and no prior exposure to diagnostic contrast media. Immediate allergic reactions which can occur on first exposure are most likely caused by which of the following mechanisms:
a. Immune complex dependent reactions
b. Non-immune cutaneous reactions
c. Ige dependent reactions
d. Mast cell degranulation

Answer 172

d. Mast cell degranulation

The patient’s presentation (urticaria, pruritus, hypotension) after contrast administration suggests an immediate hypersensitivity reaction to the contrast media. However, such reactions to iodinated contrast agents are often non-IgE-mediated and are instead caused by direct activation of mast cells and basophils, leading to degranulation.

Question 173

A 55-year-old female consults for erythematous pustular lesions in the face with noted flushing associated with alcohol intake. Physical exam demonstrates erythematous papulopustular lesions with severe signs of inflammation and telangiectasia. Which is the best therapy to prescribe?
a. Topical glucocorticoids
b. Topical ivermectin
c. Oral glucocorticoids
d. Oral Doxycycline

Answer 173

d. Oral Doxycycline

The patient’s presentation is consistent with papulopustular rosacea, a subtype characterized by erythematous papules, pustules, telangiectasia, and associated flushing. In this case, the severity of inflammation and the presence of numerous papulopustular lesions warrant systemic therapy.

Why the Other Options Are Incorrect:
a. Topical glucocorticoids:
Topical steroids are not recommended for rosacea as they can exacerbate symptoms (steroid-induced rosacea).

b. Topical ivermectin:
Effective for mild to moderate papulopustular rosacea but insufficient for severe cases with systemic involvement.

c. Oral glucocorticoids:
Not indicated for rosacea; reserved for severe, refractory inflammatory diseases.

Question 174

A 25-year-old student was referred for scalp itchiness. He initially dismissed the condition as simple dandruff but became anxious when the eyebrows, eyelashes and glabella were involved. He has central facial erythema with overlying greasy, yellowish scale. What is your best advise?
a. He needs high-potency topical glucocorticoid (betamethasone or clobetasol) for control of severe scalp involvement.
b. It does not spread to other areas of the body like the chest, groin, axilla and gluteal cleft.
c. Antidandruff shampoos are effective if left in place for 30 min before rinsing.
d. No treatment is necessary as it is self-limiting.

Answer 174

a. He needs high-potency topical glucocorticoid (betamethasone or clobetasol) for control of severe scalp involvement.

Question 175

An excessive accumulation of stratum corneum is a secondary skin lesion called
A. Scale
B. Crust
C. Lichenification
D. Excoriation

Answer 175

A. Scale

Question 176

33/F recently returned from a trip to Palawan where she took prophylactic antimalarial medications. After 1 week, she complained of severe pruritic rashes over both wrists and both lower extremities. She has no known comorbidities with no significant drug history or allergy. Skin exam reveals multiple flat topped violaceous papules and plaques with note of Wickham’s striae over both wrists and anterior lower leg areas. Her fingernails were dystrophic. What is the next best step?
A. Do skin biopsy
B. Send skin scraping specimen for KOH test
C. Start mometasone ointment
D. Start cloxacillin antibiotics

Answer 176

C. Start mometasone ointment

Lichen planus –> flat topped violaceous papules and plaques
Tx: steroids

Question 177

A 42-year-old man, is recently diagnosed with HIV and has a CD4 count of 100. He is currentlyhospitalized due to pneumonia and receiving several courses of antibiotics. While doing rounds, he complains of discomfort and white patches on his tongue that he noticed while eating. On examination,creamy white, curd-like plaques are observed on the buccal mucosa and tongue. What is the best treatment
for this condition?
A. Nystatin
B. Fluconazole
C. Acyclovir
D. Hydrocortisone IV

Answer 177

B. Fluconazole

Since immunocompromised, fluco > nystatin

Question 178

45/F with chronic psoriasis complains of severe pain and deformities of the small joints of both hands
and feet. What is this type of psoriatic arthritis?
A. Symmetric
B. Asymmetric
C. Distal psoriatic arthritis
D. Arthritis mutilans

Answer 178

D. Arthritis mutilans

Question 179

A 28-year-old male, visits your clinic complaining of sudden hair loss. He reports noticing several coinsized, well-defined, bald patches on his scalp. There is no associated redness, scaling, or pain in the affected areas. He denies a history of recent illness or major life stressors nor any use of hairgel. What is the underlying pathogenesis of this condition?
A. Larger numbers of growing (anagen) hairs simultaneously enter the dying (telogen) phase
B. Increased sensitivity of affected hairs to the effects of androgens
C. The germinative zones of the hair follicles are surrounded by T lymphocytes
D. Mechanical pulling or by traction

Answer 179

C. The germinative zones of the hair follicles are surrounded by T lymphocytes

Alopecia areata

Question 180

A 45/M farmer taking tetracycline for a week sought
consult due to erythematous patches, stinging, and
mild pruritus on the face, nape, neck, and dorsa of both
arms. On further physical examination, the area under
the chin was spared. No lesions were noted on the
chest, abdomen, and back. What is the cause of the
patient’s clinical presentation?
A. Pigmentary changes due to drugs
B. Urticaria
C. Photosensitivity eruptions
D. Fixed drug eruption

Answer 180

C. Photosensitivity eruptions

Photosensitivity eruptions are usually most marked in sun-exposed areas, but they may extend to sun-protected areas. The mechanism is almost always phototoxicity. Common orally administered photosensitizing drugs include fluoroquinolones, tetracycline antibiotics, and trimethoprim/sulfamethoxazole. Other drugs less frequently implicated are chlorpromazine, thiazides, NSAIDs, and BRAF inhibitors. Voriconazole may result in severe photosensitivity, accelerated photoaging, and cutaneous carcinogenesis

Question 181

A 63/F is on multiple medications for her rheumatoid arthritis, diabetes, and asthma. She recently developed a cutaneous drug reaction to one of her medications. You decided to do further testing to determine which specific drug caused her cutaneous drug reaction. Which of the following statement is true in determining the causality of a specific drug?
A. In vitro immunologic assays are now used by laboratories for accurate diagnosis.
B. Diagnostic rechallenge can be done even for drugs withhigh rates of adverse reactions.
C. The usefulness of laboratory tests, skin prick, or patch testing to determine causality has good practical value.
D. Two-thirds of patients with positive skin test carries 1% risk of anaphylaxis

Answer 181

B. Diagnostic rechallenge can be done even for drugs withhigh rates of adverse reactions.

Question 182

A 43/M came to the clinical for consult. He was prescribed with topical corticosteroids for his dermatitis. However, he now presents with worsening symptoms, including increased redness, pain, and weeping lesions in the antecubital fossae. What is the most likely organism causing patient’s clinical manifestation?
A. Escherichia coli
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Streptococcus pyogenes

Answer 182

C. Staphylococcus aureus

Question 183

A 40/M, presents with a chronic pruritic lesion on his left forearm that has been worsening over the past 6 months. Despite trying various over-the-counter creams, he has not experienced significant relief. On examination, a well demarcated, hyperpigmented plaque with lichenification and scratch marks is noted on the left forearm. What is the best management for the case?
A. High-potency topical corticosteroid creams or ointments
B. Moisturizers and emollients
C. Topical calcineurin inhibitors
D. Topical glucocorticoids under occlusion or intralesional injection of glucocorticoids

Answer 183

D. Topical glucocorticoids under occlusion or intralesional injection of glucocorticoids

Lichen simplex chronicus may represent the end stage of a variety of pruritic and eczematous disorders, including AD. It consists of a circumscribed plaque or plaques of lichenified skin due to chronic scratching or rubbing.

Common areas involved include the posterior nuchal region, dorsum of the feet, and ankles. Treatment of lichen simplex chronicus centers on breaking the cycle of chronic itching and scratching.

High-potency topical glucocorticoids are helpful in most cases, but, in recalcitrant cases, application of topical glucocorticoids under occlusion or intralesional injection of glucocorticoids may be required.

Question 184

A 43/M consulted at the clinic with complaints of worsening skin lesions. He has a known history of psoriasis, which was initially diagnosed 10 years ago. Recently, he developed fatigue, generalized malaise, abdominal pain, and yellowing of the skin and eyes. Which drug is the likely offending agent?
A. Acitretin
B. Apremilast
C. Cyclosporine
D. Methotrexate

Answer 184

D. Methotrexate

Adverse effects of methotrexate include hepatotoxicity, pulmonary toxicity, pancytopenia, potential for increased malignancies, ulcerative stomatitis, nausea, diarrhea, and teratogenicity. Adverse effects of other choices:

A - Teratogenicity, hepatotoxicity, hyperostosis, hyperlipidemia, pancreatitis, depression, ophthalmologic effects, pseudotumor cerebri
B - Hypersensitivity reaction, depression, nausea, diarrhea, vomiting, dyspepsia, weight loss, headache, fatigue
C - Renal dysfunction, hypertension, hyperkalemia, hyperuricemia, hypomagnesemia, hyperlipidemia, increased risk of malignancies

Question 185

HIV medication associated with lactic acidosis, lipid abonormalities and hyperglycemia

Answer 185

Zidovudine

Ritonavir can also cause lipid abnormalities and hyperglycemia

Question 186

HIV medication associated with abnormal dreams

Answer 186

Efavirenz

Question 187

HIV medication associated with PR prolongation , transaminase elevaation, renal stones

Answer 187

Atazanavir

Question 188

HIV medication associated with inc rate of bacterial pneumonia

Answer 188

Enfurvitide

Question 189

HIV medication associated with rhabdomyolysis

Answer 189

Raltegravir

Question 190

Most common sites of angioedema

Answer 190

Periorbital and Perioral

Question 191

Initial dx test for CHRONIC urticaria should include these lab tests

Answer 191

CBC with assessment of eosinopilia
ESR
TSH

Question 192

Prophylaxis for acute HAE attacks

Answer 192

Infusion of isolated or recombinant C1 INH protein

Question 193

Treatment of acute HAE

Answer 193

Bradykinin 2 receptor antagonist (Icatibant)
Kallikrein inhibitor (Ecallantide)

Question 194

Hallmarks of allergic rhinitis

Answer 194

Episodic rhinorrhea
Sneezing
Obstruction of nasal passages
Lacrimation
Pruritus

Question 195

Nasal antihistamine with dysgeusia as side effect

Answer 195

Azelastine and Olopatadine

Question 196

Contraindication of pseudoephedrine

Answer 196

Narrow angle glaucoma
urinary retention
Severe hypertension
Marked CAD
1st trimester pregnancy

Question 197

Contraindications of Immunotherapy (Hyposensitization)

Answer 197

Significant CV dse
Unstable asthma
Caution in any px on BB

Question 198

What is the underlying pathology in patients who die from anaphylaxis without antecedent respiratory insufficiency?

a. Visceral congestion leading to loss of intravascular volume
b. Mechanical laryngeal obstruction
c. Bronchospasm and peribronchial congestion
d. Volume depletion due to profuse vomiting

Answer 198

a. Visceral congestion leading to loss of intravascular volume

Question 198

A 20/F presented in the OPD due to recurrent urticaria. On probing, you note that the wheals often show up on her bilateral shoulders after a long day of carrying her backpack around. Which of the following is NOT an appropriate treatment for this patient?

a. H1 antagonist
b. H2 antagonist
c. CysLT1 receptor antagonist
d. Topical steroid

Answer 198

d. Topical steroid

No value in urticaria

Question 199

Which of the following conditions involve deficiency in the innate immune system?

a. IgA deficiency
b. DiGeorge’s syndrome
c. Leukocyte adhesion deficiency
d. Severe-combined immune deficiency

Answer 199

c. Leukocyte adhesion deficiency

Question 200

Which of the following is a risk factor for developing allergic rhinitis?

a. Male sex
b. Younger age
c. Maternal smoking
d. Being underweight

Answer 200

c. Maternal smoking

Question 201

Which of the following responses is associated with biopsy findings of infiltrating and activated TH2 cells and various leukocytes?

a. Skin erythema with swelling
b. Wheal-and-flare response with pruritus
c. Bronchospasm and mucus secretion
d. Nasal pruritus and watery discharge

Answer 201

a. Skin erythema with swelling

ALLERGIC INFLAMMATION
Immediate phase
* Pruritus and watery discharge in the nose
* Bronchospasm and mucus secretion in the lung
* Wheal-and-flare response with pruritus in the skin

Late phase (6-8 hrs)
* Reduced nasal patency
* Reduced pulmonary function
* Erythema with swelling at the skin site
* Biopsy findings: Infiltrating and activated TH2 cells, eosinophils, basophils, and some neutrophils

Question 202

During which decades are chronic urticaria/angioedema the most common?

a. Second to fourth
b. Third to fifth
c. Fourth to sixth
d. Fifth to sevenths

Answer 202

b. Third to fifth

CHRONIC URTICARIA/ANGIOEDEMA

Can occur at any time, with the third to fifth decade being the most common
Women > men
Slight predominance for those with a history of atopy

Question 203

Who among the following could be the most at risk for ACE inhibitor related angioedema?

a. White male
b. Elderly smoker
c. Young asthmatic
d. Female cancer patient

Answer 203

b. Elderly smoker

RISK FACTORS FOR ACE-INHIBITOR RELATED ANGIOEDEMA
* Black race
* Organ transplant
* Female gender
* Smoking
* Increasing age

Question 204

Which of the following types of physical urticaria is not influenced by atopy?

a. Cholinergic
b. Cold
c. Dermatographic
d. Solar

Answer 204

c. Dermatographic

DERMOGRAPHISM/DERMATOGRAPHISM
* Appearance of a linear wheal with surrounding erythema at the site of a brisk stroke with a firm object
* Peaks in the second to third decades
* Duration generally <5 years
* Not influenced by atopy

Question 205

Which of the following is the best evidence for IgE and mast cell involvement in urticaria and angioedema?

a. Cholinergic urticaria
b. Cold urticaria
c. Pressure urticaria
d. Urticaria pigmentosa

Answer 205

b. Cold urticaria

COLD URTICARIA
* Cryoglobulins or cold agglutinins are present in up to 5%
* Histology: Marked mast cell degranulation with associated edema of the dermis and subcutaneous tissues
* Elevated histamine levels

Question 206

Which of the following is the most likely diagnosis in a patient presenting with isolated angioedema and abdominal colic, nausea, and vomiting?

a. C1 inhibitor deficiency
b. Gleich syndrome
c. Mastocytosis
d. Urticarial vasculitis

Answer 206

a. C1 inhibitor deficiency

BRADYKININ-MEDIATED ANGIOEDEMA (ACE INHIBITORS/C1INH DEFICIENCY)
* Absence of concomitant urticaria or pruritus
* Frequent involvement of the GI tract
* Duration of symptoms >24 hrs
* *Gleich syndrome = episodic angioedema with eosinophilia

Question 207

Which of the following histologic features is most likely to be found in a patient complaining of prolonged episodes of painful and nonpruritic urticaria with resultant scarring?

a. Adventitial and medial fibrosis
b. Fibrinoid necrosis of the venules
c. Perivascular lymphocytic infiltrate
d. Necrotizing granulomatous inflammation of vessel walls

Answer 207

b. Fibrinoid necrosis of the venules

URTICARIAL VASCULITIS
* Painful, nonpruritic urticarial lesions that last >36 hrs with subsequent scarring
* Warrants biopsy
o Cellular infiltration and nuclear debris (leukocytoclastic vasculitis)
o Fibrinoid necrosis of the venules

Question 208

Which of the following is the next line of therapy for a patient with recurrent episodes of hives and wheezing upon exposure to low ambient temperatures that does not adequately respond to first-line treatments?

a. Cyclosporine
b. Hydroxychloroquine
c. Methylprednisolone
d. Omalizumab

Answer 208

d. Omalizumab

COLD URTICARIA

IgE and mast cell involvement
Omalizumab (monoclonal anti-IgE antibody) – next line of therapy for chronic urticaria which has failed to respond to a combination of long-acting H1 antihistamines QID and a CysLT1 receptor antagonist or cold urticaria

Question 209

For which of the following types of urticaria should the addition of systemic glucocorticoids be considered in the presence of severe disease that is poorly responsive to conventional therapies?

a. Allergen-induced
b. Cold
c. Cholinergic
d. Pressure

Answer 209

d. Pressure

SYSTEMIC GLUCOCORTICOIDS
Useful in patients with debilitating disease that responds poorly to conventional treatment:
* Pressure urticaria
* Vasculitic urticaria (esp. with eosinophil prominence)
* Idiopathic angioedema ± urticaria
* Chronic urticaria

Generally avoided due to long-term toxicity:
* Idiopathic urticaria
* Allergen-induced urticaria
* Physical urticarias

Question 210

Which of the following medications is an appropriate option for a patient experiencing sneezing and ocular itching around 2 days a week with no impairment in sleep or daily activities?

a. Intranasal glucocorticoid
b. Intranasal ipratropium bromide
c. Oral corticosteroid
d. Oral antihistamine

Answer 210

d. Oral antihistamine

MILD INTERMITTENT AR
* <4 days/week or
* <4 weeks
* No troublesome symptoms or impairment in sleep/daily activities

ARIA 2008

Question 211

Which of the following medications is the best option for a patient suffering from daytime somnolence and fatigue due to allergic rhinitis symptoms occurring around 4 days a week for 2 weeks?

a. CysLT1 receptor antagonist
b. Intranasal glucocorticoid
c. Intranasal ipratropium bromide
d. Oral corticosteroid

Answer 211

b. Intranasal glucocorticoid

MODERATE-SEVERE INTERMITTENT AR
* <4 days/week, or
* <4 weeks
* (+) Troublesome symptoms or impairment in sleep/daily activities

Question 212

Intranasal decongestants should be given for less than how many days to prevent rhinitis medicamentosa?

a. 10
b. 14
c. 21
d. 30

Answer 212

a. 10

RHINITIS MEDICAMENTOSA
Rebound nasal congestion that occurs with prolonged use (more than 10 days) of topical decongestants such as oxymetazoline and phenylephrine

Question 213

In patients with seasonal allergic rhinitis, which of the following concomitant conditions might make them benefit more from a CysLT1 receptor antagonist vs. an oral antihistamine?

a. Allergic conjunctivitis
b. Brittle asthma
c. Exercise-induced bronchoconstriction
d. Postnasal drip

Answer 213

c. Exercise-induced bronchoconstriction

Question 214

What are the most commonly involved vessels in cutaneous vasculitides?

a. Capillaries
b. Vasa vasorum
c. Terminal arterioles
d. Postcapillary venules

Answer 214

d. Postcapillary venules

HISTOLOGIC FINDINGS IN CUTANEOUS VASCULITIDES
* Postcapillary venules – most commonly involved vessels
* Acute: Leukocytoclasis (nuclear debris remaining from the neutrophils that have infiltrated in and around the vessels)
* Subacute/chronic: Mononuclear cell infiltration

Question 215

Which of the following is a risk factor for increased mortality from anaphylaxis?

a. Asian ethnicity
b. History of beta agonist use
c. Preexisting bronchial asthma
d. Young age

Answer 215

c. Preexisting bronchial asthma

RISK FACTORS FOR RAPID DECOMPENSATION FROM ANAPHYLAXIS
(a) Underlying cardiovascular disease
* one of the most dangerous manifestations of anaphylaxis is involvement of the cardiovascular system
(b) Underlying bronchial asthma
* predisposed to having severe involvement of the lower airways –> leading to increased mortality

Question 216

History of atopy increases the risk for which type of anaphylactic reaction?

a. Exercise-induced anaphylaxis
b. Severe hymenoptera sting
c. Anaphylaxis from insulin
d. Anaphylaxis from penicillin

Answer 216

a. Exercise-induced anaphylaxis

ATOPY
* Increases risk of:
(a) exercise-induced anaphylaxis
(b) Idiopathic anaphylaxis
(c) Latex-induced anaphylaxis
(d) Radiocontrast allergy
(e) Food allergy
* Not associated with:

(a) Drug allergies (insulin, penicillin, muscle relaxants
(b) Hymenoptera stings

Question 217

Which gastrointestinal finding in anaphylaxis may contribute to possible cardiovascular collapse?

a. Angioedema of intestinal wall
b. Bowel ischemia
c. Bowel ulceration
d. Ileus

Answer 217

a. Angioedema of intestinal wall

Question 218

Which case exhibits an IgE-mediated hypersensitivity reaction?

a. A 60/F with ovarian cancer, developing urticarial lesions during her first carboplatin infusion
b. A 24/F developed auricular wheals 3 days after she had new ear piercings
c. A 45/M, post kidney transplant with antibody-mediated rejection, developed arthalgias, fever, and maculopapular eruptions on the face and torso 5 days after infusion of Anti-thymocyte globulin
d. A 7/M with wheals 4 days after accidental contact with poison ivy plant

Answer 218

a. A 60/F with ovarian cancer, developing urticarial lesions during her first carboplatin infusion

TYPES OF HYPERSENSITIVITY REACTIONS
(A) Type 1: Immediate hypersensitivity
IgE-mediated drug allergies are most common with antibiotics and certain chemotherapeutic agents (notably platinum-based)
(B) Type II: Antibody-dependent reaction
Hemolytic anemia
(C) Type III: Immune complex reaction
Serum sickness, SLE
(D) Type IV: Delayed type hypersensitivity
Contact dermatitis, PPD test

Question 219

Which is true regarding the use of serum biomarkers in anaphylaxis?

a. Serum histamine is a practical biomarker to determine severity of anaphylaxis.
b. An elevated baseline serum histamine level should prompt the clinician to investigate possible mastocytosis.
c. Serum tryptase level can remain elevated as long as 5 hours after the episode of anaphylaxis.
d. A second serum tryptase determination after an elevated initial test is not recommended.

Answer 219

c. Serum tryptase level can remain elevated as long as 5 hours after the episode of anaphylaxis.

SERUM BIOMARKERS
(a) Serum histamine
* Can only remain elevated up to 1 hour from onset of anaphylaxis

(b) Serum tryptase: more practical
* Peaks at 60-90 minutes after onset of symptoms
* Elevated up to 5 hours after episode of anaphylaxis
* Elevated baseline level may warrant work-up for mastocytosis
* Another determination is helpful (after resolution of symptoms) to establish baseline
* May not be elevated in food allergy

Question 220

Which of the following leads to ‘empty heart syndrome’ in cases of anaphylaxis?

a. Patient in the supine position
b. Epinephrine use
c. Administration of vasopressor agents
d. Vigorous fluid resuscitation

Answer 220

b. Epinephrine use

EMPTY HEART SYNDROME
* Insufficient venous return to the heart from sudden onset hypotension secondary to intravascular volume depletion
* Epinephrine accelerates empty heart syndrome (chronotropic effect of drug)
* In the acute setting, patients should be placed in supine position when receiving epinephrine
* Vasopressor support and IV fluids should be given to patients with refractory hypotension

Question 221

Which is true of desensitization?

a. It entails the administration of incremental increases in doses of the drug to induce permanent tolerance.
b. It is effective for penicillin and platinum-based chemotherapy allergies.
c. It works best for non IgE-mediated reactions.
d. Hypersensitivity to the drug does not recur when the medication is discontinued or treatment is interrupted.

Answer 221

b. It is effective for penicillin and platinum-based chemotherapy allergies.

DRUG DESENSITIZATION
* Elicits temporary state of tolerance to the drug in sensitized patients
* Established technique in penicillin allergy
* Also effective for platinum-based chemotherapeutic agents
* Shown to work best in IgE-mediated reactions
* If patient is receiving drug in regular intervals, a desensitized state can be maintained

Question 222

A 60-kg male will undergo abdominal CT scan with triphasic contrast for surveillance of treated liver cancer. On review of systems, he recalled appearance pruritic rashes during last year’s CT scan. What is the correct dose and frequency of his premedication regimen prior to contrast?

a. Prednisone 30 mg tablet, 6- and 1 hour prior to CT scan + Diphenhydramine 25 mg
b. Prednisone 60 mg tablet, 6- and 1 hour prior to CT scan + Diphenhydramine 25 mg
c. Prednisone 30 mg tablet, 13-, 6-, and 1 hour prior to CT scan + Diphenhydramine 25 mg
d. Prednisone 60 mg tablet, 13-, 6-, and 1 hour prior to CT scan + Diphenhydramine 25 mg

Answer 222

c. Prednisone 30 mg tablet, 13-, 6-, and 1 hour prior to CT scan + Diphenhydramine 25 mg

PREMEDICATION REGIMEN PRIOR TO RADIOCONTRAST
(a) Prednisone 0.5 mg/kg, 13-, 6-, and 1 hour prior

(b) Diphenhydramine 25 mg

Question 223

Which is true regarding biphasic anaphylaxis?

a. This is a clinical entity wherein signs and symptoms do not fully respond to initial treatment.
b. It is more common than uniphasic anaphylaxis.
c. Signs and symptoms recur less than an hour after onset of initial anaphylactic reaction.
d. Signs and symptoms may recur as late as 72 hours after resolution of initial reaction.

Answer 223

d. Signs and symptoms may recur as late as 72 hours after resolution of initial reaction.

BIPHASIC ANAPHYLAXIS
* Less common than uniphasic reactions (80-90% of anaphylactic reactions are uniphasic)
* Biphasic anaphylaxis: defined as recurrent anaphylaxis after complete improvement
* Must be clinically differentiated from an episode that does not fully respond to treatment
* Reported to occur between 1 to 72 hours after resolution of initial reaction

Question 224

Which of the following primary immunodeficiencies is secondary to impaired development of T lymphocytes?

a. Ataxia telangiectasia
b. Common variable immune deficiency (CVID)
c. Severe combined immune deficiencies (SCID)
d. Wiskott—Aldrich Syndrome

Answer 224

c. Severe combined immune deficiencies (SCID)

Question 225

What is the hallmark of severe congenital neutropenia (SCN)?

a. Absence of pus
b. Florid mycobacterial infections
c. Localized fungal soft tissue infections
d. Refractory to GCSF

Answer 225

a. Absence of pus

SEVERE CONGENITAL NEUTROPENIA (SCN)
* A PID of the innate immune system
* Characterized by severely impaired neutrophil counts
* Bacterial and fungal infections rapidly disseminate through bloodstream
* Absence of pus is the hallmark of SCN
* In most cases, neutrophil counts improve with injection of GCSF
o Exception: + ELANE mutation (refractory to GCSF); same subset of patients are at increased risk of AML

Question 226

Which is true of infections arising from chronic granulomatous diseases (CGD)?

a. Fungal elements are rarely isolated from deep tissue abscesses in the lungs and lymph nodes.
b. Recurrent skin infections are uncommon.
c. Macrophage-rich granulomas seen in the liver and spleen are often sterile.
d. Granulomatous lesions are mostly steroid-refractory.

Answer 226

c. Macrophage-rich granulomas seen in the liver and spleen are often sterile.

CHRONIC GRANULOMATOUS DISEASES
* Bacterial and fungal abscesses are usually seen; in fact, prophylactic regimen includes azole derivatives
* Recurrent skin infections, such as folliculitis, are common– that these prompt early diagnosis of disease
* Granulomas are often sterile and steroid-responsive

Question 227

Which subset of CD4 T helper cells is activated when the immune system encounters Mycobacterium tuberculosis?

a. TH1
b.TH2
c.TH9
d.TH17

Answer 227

a. TH1

Question 228

40/F with three pregnancy losses is being worked up for reproductive immune disorders. On lymphocyte subset enumeration, elevated CD16/56 levels were the only abnormal finding. What could possibly explain this?
a. Allergen immunotherapy
b. Breast cancer
c. HIV-1 infection
d. Parasitic infection

Answer 228

b. Breast cancer

Elevated levels of CD16/56+ natural killer (NK) cells can be associated with several conditions, including reproductive immune disorders, malignancies, and immune system dysregulation.

Question 229

T cells must maintain tolerance to self antigens to avoid causing damage to cells. Which of the following demonstrates central tolerance of T cells?

a.T-cell anergy
b.Suppression by regulatory T cells
c.Clonal deletion in the lymph nodes
d.Modification of T cell receptors

Answer 229

d.Modification of T cell receptors

Question 230

A 32/M is referred for recurrent abscesses in the lungs and liver. TB workups are negative, and the organism isolated is usually Staphylococcus. HIV test is negative. If his dihydrorhodamine fluorescence assay is positive, what is the underlying pathophysiology of his condition?

a.Defective interferon-dependent macrophage activation
b.Defective neutrophil development from precursor
c.Defective neutrophil migration to infected tissues
d.Defective reaction oxygen species production

Answer 230

d.Defective reaction oxygen species production

The patient’s presentation of recurrent abscesses caused by catalase-positive organisms like Staphylococcus suggests chronic granulomatous disease (CGD). A positive dihydrorhodamine (DHR) fluorescence assay indicates defective production of reactive oxygen species (ROS) by neutrophils.

Question 231

A 25/M is referred for chronic bronchiectasis. He was treated for PTB twice due to apical infiltrates in his x-ray during his younger years, but all sputum samples were negative for MTB. He had frequent respiratory tract infections in childhood necessitating hospitalizations and IV antibiotics. Which of the following diagnostics would be most useful to investigate possible primary immunodeficiency in his case?

a.Absolute neutrophil count
b.Classic complement pathway assay
c.Post vaccination titers
d.Tuberculin skin testing

Answer 231

c.Post vaccination titers

The patient’s history of chronic bronchiectasis, recurrent respiratory infections requiring IV antibiotics, and repeated treatment for suspected tuberculosis despite negative sputum tests raises the suspicion of primary immunodeficiency, particularly antibody deficiency disorders such as common variable immunodeficiency (CVID) or specific antibody deficiency.

Question 232

27/F presents with 2-month history of angioedema without wheals or pruritus. Which laboratory test can be used as a screening test for this disease?

a.Histamine
b.Complement levels
c.Serum IgE
d.Tryptase

Answer 232

b.Complement levels

This presentation is consistent with hereditary angioedema (HAE) or acquired angioedema (AAE), particularly since the angioedema is non-pruritic, without wheals, and has persisted for 2 months. These features strongly suggest bradykinin-mediated angioedema, not histamine-mediated processes like allergic reactions

Screening Test: Complement Levels
C4 levels:
C4 is typically low in both hereditary and acquired angioedema.
It is a sensitive and cost-effective screening test for these conditions.

C1 inhibitor (C1-INH):
If C4 is low, further testing for C1-INH levels and function can confirm the diagnosis.
In HAE, C1-INH is deficient (Type I) or dysfunctional (Type II).
In AAE, C1-INH is consumed due to an underlying condition like lymphoma or autoantibodies.

Question 233

What is TRUE about the pathology in urticaria?

a.It is characterized by edema of the subcutaneous tissue and deep dermis.
b.The perivenular infiltrate consists of lymphocytes, monocytes, eosinophils and neutrophils.
c.Collagen bundles in the affected areas are packed tightly.
d.The venules are always constricted

Answer 233

b.The perivenular infiltrate consists of lymphocytes, monocytes, eosinophils and neutrophils.

Question 234

Which of the following is part of the late cellular phase of allergic inflammation?
a.Reduced pulmonary function
b.Mucus secretion
c.Watery nasal discharge
d.Wheal and flare

Answer 234

a.Reduced pulmonary function

Question 235

Which of the following antihistamines may be safely increased to four times the amount of the daily dose in the treatment of chronic urticaria?
a.Chlorpheniramine
b.Diphenhydramine
c.Fexofenadine
d. Hydroxyzine

Answer 235

c.Fexofenadine

In the treatment of chronic urticaria, second-generation antihistamines like fexofenadine can be safely increased up to four times the standard daily dose when symptoms are inadequately controlled with the regular dose.

Question 236

28/F with bronchial asthma complains of nasal congestion, rhinorrhea and sneezing occurring daily for several months. She was prescribed an intranasal glucocorticoid/antihistamine spray and Montelukast but she still complains of difficulty sleeping due to nasal congestion. She also underwent skin prick testing which was positive to house dust mite, and she has since practiced environmental allergen control measures. What can be an additional treatment for this patient’s allergic rhinitis that is also beneficial for her asthma?

a.Immunotherapy
b.Oral glucocorticoids
c.Nasal decongestants
d.Intranasal ipratropium bromide

Answer 236

a.Immunotherapy

Question 237

An 81/F church volunteer consults the clinic for episodes of purulent rhinosinusitis and dyspnea, worsened by exposure to incense and dust. She claims she recently developed an allergy to painkillers. Serum specific IgE to aeroallergens were negative, while serum eosinophil levels were elevated. What would be the most likely diagnosis for this patient?

a.Allergic rhinosinusitis with upper airway cough syndrome
b.Aspirin-exacerbated respiratory disease
c.Atrophic and vasomotor rhinitis in the elderly
d.Non-allergic rhinitis with eosinophilic syndrome

Answer 237

b.Aspirin-exacerbated respiratory disease

Question 238

Which of the following T cells activate and recruit eosinophils and other cells required to fight helminthic infections?
a. CD4+ TH1 cells
b. CD4+ TH2 cells
c. CD4+ TH17 cells
d. Cytotoxic CD8+ T cells

Answer 238

b. CD4+ TH2 cells

T CELL EFFECTORS
* CD4+ TH1 cells: help in intracellular killing of Salmonella and mycobacterial infections
* CD4+ TH2 cells: activate eosinophils, among others, to help fight helminthic infections
* CD4+ TH17 cells: recruit neutrophils to skin and lungs to fight bacterial and fungal infections
* Cytotoxic CD8+ T cells: kill infected cells (viral infections)

Question 239

Which is true of severe combined immune deficiencies (SCID)?

a. Failure to thrive and recurrent oral fungal infections are frequent manifestations of the disease.
b. Bacille Calmette-Guarin (BCG) vaccine can be safely given to infants with SCID.
c. Pneumocystis jiroveci pneumonia is exclusively seen in children afflicted with this T cell immunedeficiency.
d. Severe infections and other clinical consequences occur after the first year of life.

Answer 239

a. Failure to thrive and recurrent oral fungal infections are frequent manifestations of the disease.

SCID
* Most common manifestations: protracted diarrhea, recurrent oral candidiasis, and failure to thrive
* P. jiroveci pneumonia may also be seen during the first year of life in patients with B cell immunedeficiencies
* Administration of BCG vaccine may lead to complications, such as local and disseminated fatal infections
* These severe clinical consequences occur early in life (within 3 to 6 months of birth)

Question 240

Which of the T cell immunodeficiencies places the affected individual at very high risk for development of hematopoietic and solid organ malignancies in his lifetime?

a. Ataxia-telangiectasia
b. Dyskeratosis congenita
c. Omenn Syndrome
d. SCID

Answer 240

a. Ataxia-telangiectasia

IMMUNODEFICIENCY WITH ATAXIA-TELANGIECTASIA
* T cell primary immunodeficiency associated with DNA repair defects
* Progressive disease
* Hallmark features: cerebellar ataxia and telangiectasia
* Affected individuals are at very high risk for lymphomas, leukemia, and carcinomas in adulthood

Question 241

Which B cell immunodeficiency can be a manifestation of myelodysplastic syndrome?

a. Agammaglobulinemia
b. Common variable immunodeficiency (CVID)
c. Hyper IgM syndrome
d. IgA deficiency

Answer 241

a. Agammaglobulinemia

Question 242

Which of the following is a common clinical manifestation of Wiskott-Aldrich Syndrome?

a. Alopecia
b. Cerebellar ataxia
c. Eczema
d. Pneumatoceles from complicated respiratory infections

Answer 242

c. Eczema

WATER

Wiskott Aldrich –> Thrombocytopenia, Eczema Recurrent infection

Question 243

Which is the most frequent trigger of Hemophagocytic lymphohistiocytosis (HLH)?

a. CMV infections
b. EBV infections
c. Streptococcal infections
d. Enteroviral infections

Answer 243

b. EBV infections

HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH)
* Characterized by unremitting activation of CD8+ T cells and macrophages that lead to organ damage
o Often induced by viral infections
* Most frequent: EBV infections

Question 244

Which of the following strongly suggests SCID?

a. Eosinophilia
b. Lymphocytopenia
c. Neutropenia
d. Platelet clumping

Answer 244

b. Lymphocytopenia

DIAGNOSIS OF SCID
* Lymphocytopenia – strongly suggests SCID (seen in at least 90% of cases)
* Caveat: this may be masked by presence of maternal T cells (derived by maternal-fetal blood transfers)

Question 245

Which is true regarding management of SCID?

a. Hematopoietic stem cell transplantation (HSCT) is often not curative.
b. SCID does not respond to immunoglobulin replacement.
c. Gene therapy is effective in all phenotypes of SCID.
d. Aggressive antimicrobial prophylaxis/treatment should be instituted.

Answer 245

d. Aggressive antimicrobial prophylaxis/treatment should be instituted.

TREATMENT OF SCID
* Anti-infective therapies
* Nutritional support
* Immunoglobulin replacement
* HSCT: high curative potential

Question 246

A 55 year old female sought consult after developing pruritic, red wheals of varying sizes at the torso, and both upper and lower extremities that started last night. She also complained of body malaise and fever up to 38.3o C which was relieved with paracetamol. She denies any allergies to food and medications. However, around a week ago, she visited the local health center to get injected with tetanus toxoid after a pedicure accident. What classification of allergic reaction would most likely explain the patient’s symptoms?
a. Type I: IgE-mediated
b. Type II: IgG mediated cytotoxicity
c. Type III: Immune-complex mediated
d. Type IV: T-lymphocytic mediated inflammation

Answer 246

c. Type III: Immune-complex mediated

Question 247

A 30 year old woman came in for 1 week history of cough with nasal catarrh. She was treated as a case of Community Acquired Pneumonia Low Risk, and was started on Cefaclor 500 mg/tablet 1 tablet BID. She subsequently developed generalized pruritic rash, joint pains, and fever. She improved upon treatment with systemic steroids. Available laboratories showed normal CBC, Creatinine and Complement Levels. Which one of the following diagnoses is most likely in this case?
A. Serum sickness reaction to Cefaclor
B. Serum sickness-like reaction to Cefaclor
C. Delayed-type hypersensitivity reaction to Cefaclor
D. Immunoglobulin E–mediated allergy to Cefaclor

Answer 247

A. Serum sickness reaction to Cefaclor

Question 248

Which of the following statements is true regarding allergic rhinitis?
a. Almost 70-80% of patients with allergic rhinitis have asthma
b. In the acute attack of allergic rhinitis, TH1-mediated inIammation predominate over TH2-mediated inIammation
c. Total serum IgE is usually elevated and is enough to establish the etiologic diagnosis
d. It involves interaction occurs between the allergen and intraepithelial mast cells as well as deeper perivenular mast cells

Answer 248

d. It involves interaction occurs between the allergen and intraepithelial mast cells as well as deeper perivenular mast ce

a– 50% of px with allergic rhinitis have asthma
b TH2 >TH1

Question 249

A 34 year old American male tourist was rushed to the emergency room due to severe dyspnea after eating karekare in a turo-turo restaurant. He was previously diagnosed to have peanut allergy and was previously attempteddesensitization but failed.
Which of the following statements is true regarding his condition?
a. Typical symptom onset ranges from a few minutes to a few hours after exposure to offending agent
b. People with asthma are at increased risk of dying from this condition
c. Cutaneous manifestations are rare, typically involving only <10% of the cases; majority of the symptoms are respiratory
d. Histamine release causes fIushing, urticaria, pruritus and bronchoconstriction

Answer 249

b. People with asthma are at increased risk of dying from this condition

a. usually <1 hr
c. cutaneous –> majority
d. histamine does not cause bronchoconstriction

Question 250

A 18 year old college student came in to your clinic for recurrent cough with productive sputum, sometimes reported to be foul smelling. Since he was a growing child, his mother reported that his son has always been “sickly” and he had many bouts of recurrent pneumonia which were managed with unrecalled antibiotics, only to recur a few months after. High resolution chest CT scan revealed dilatation of the airways predominantly involving the lower lobes. Which of the following conditions is most likely present in the patient?
a. Cystic Fibrosis
b. Alpha-1 antitrypsin deficiency
c. Hypogammaglobulinemia
d. Non-tuberculous mycobacteria (NTM) infection

Answer 250

c. Hypogammaglobulinemia

The patient’s recurrent respiratory infections, productive cough, and bronchiectasis predominantly involving the lower lobes are suggestive of an underlying immunodeficiency disorder, specifically hypogammaglobulinemia, such as common variable immunodeficiency (CVID)

Question 251

A 50-year-old woman with breast cancer recently received her 2nd cycle of Trastuzumab, a monoclonal antibody targeting the HER/neu in breast cancer cells. The infusion was unremarkable. 2 days later, however, she developed fever with temperatures from 38.4 to 38.7C, well-circumscribed raised ovoid skin lesions with serpiginous borders, multiple joint pains, tender and swollen axillary and inguinal lymph nodes. What is the underlying pathophysiology of this reaction?
a. Immune complex
b. IgG-mediated cytotoxicity
c. T-lymphocyte mediated inflammation
d. IgE-mediated

Answer 251

a. Immune complex

The patient’s symptoms—fever, ovoid skin lesions with serpiginous borders, lymphadenopathy, and joint pains—suggest serum sickness-like reaction (SSLR), which can occur after administration of certain medications, including monoclonal antibodies like trastuzumab.

Question 252

A 24-year-old man consults you for sneezing, tearing, and itchiness of the eyes and nose for the past 3 days. He mentioned having acquired a new pet cat. He has congested nasal mucosa but no nasal polyp. He wakes up with headache on the morning of this consultation with you. Which of the following is consistent with your diagnosis?
a.You need to avoid NSAIDs for his headache as these can reproduce his symptoms
b.His condition can also develop among individuals with chronic staphylococcal colonization of the nasal mucosa
c.If he develops fever, it is likely due to secondary infection of the sinuses or the middle ear
d.Being a male is risk factor for this condition

Answer 252

c.If he develops fever, it is likely due to secondary infection of the sinuses or the middle ear

The patient’s symptoms of sneezing, tearing, nasal congestion, and itchiness that began after acquiring a cat strongly suggest allergic rhinitis. Morning headaches are common in allergic rhinitis due to nasal congestion and sinus pressure. Fever, however, is not typical of allergic rhinitis and, if present, suggests a secondary bacterial infection, such as sinusitis or otitis media.

Question 253

A 55-year-old woman was referred for rashes after an IV contrast scan. The lesions appear as oval, raised erythematous, with distinct borders and blanched center appearing on the hands, chest and back. The patient mentions the rashes to be very itchy. There is no shortness of breath. What is your initial intervention?
a. Hydrocortisone 100mg IV every 8 hours
b. Loratadine 10mg tablet PO
c. Montelukast 10mg tablet PO
d. Ranitidine 150mg tablet PO

Answer 253

b. Loratadine 10mg tablet PO

The patient’s presentation suggests acute urticaria following IV contrast administration. This is a histamine-mediated hypersensitivity reaction that is non-life-threatening (no shortness of breath or anaphylaxis is mentioned). The primary treatment for this condition is an oral second-generation antihistamine like loratadine, which effectively blocks histamine-mediated symptoms such as itching and erythema.

Question 254

KT, a 24-year old female came for evaluation of scarring rashes. 2 weeks ago, after attending a buffet party, noted wheal-like lesions on the arms and trunk, described as painful and non-pruritic. These persisted despite the intake of Diphenhydramine 25mg/cap and lesions were noted to scar and persist until today. Skin biopsy showed cellular infiltration with nuclear debris and fibrinoid necrosis with prominence of eosinophils. Management for this condition would include:
a. Clobetasol ointment
b. Montelukast
c. Mupirocin ointment
d. Prednisone

Answer 254

d. Prednisone

First-line therapy for urticarial vasculitis is systemic corticosteroids to reduce inflammation and immune activation.

Question 255

A 28/F, presents to your clinic multiple maculopapular lesion, recurrent diarrhea and abdominal pain. Bone marrow biopsy showing 50% mast cell infiltration. Serum tryptase is significantly elevated. Which of the following is the appropriate symptom directed management?
a. Proton Pump Inhibitor
b. Oral cromolyn sodium
c. Loratadine
d. Systemic glucocorticoid

Answer 255

b. Oral cromolyn sodium

Question 256

A 25/M presents with recurrent episodes of gastrointestinal colic and laryngeal edema. He denies pruritus and does not have urticarial lesions. Laboratory testing reveals a deficiency of C1INH antigen. Which type of hereditary angioedema (HAE) is most likely?
a. Type 1
b. Type 2
c. Type 3
d. Acquired C1INH deficiency

Answer 256

a. Type 1

Question 257

A 44/M had a 10-year history of epilepsy which was well controlled on sodium valproate. He recently had an episode of seizure and was prescribed with Carbamazepine. After 8 days, he presented at the ER with general malaise, fever and tachycardia. He had widespread blisters accompanied by mucosal and genital ulcerations. What is the key pathway in this case?
a. IgE
b. Immune Complex
c. T lymphocyte-mediated cytotoxic T lymphocyte inflammation
d. T lymphocyte mediated neutrophil inflammation

Answer 257

c. T lymphocyte-mediated cytotoxic T lymphocyte inflammation

Patient has SJS/TEN due to widespread blisters and mucosal ulcerations

Question 258

A 25/F, with history of recurrent crampy abdominal painand diarrhea was diagnosed with aggressive systemicmastocytosis. Which of the following is a consistentclinical feature?
A. ANC 1,500/uL
B. Hemoglobin 11 g/dL
C. Platelet 90,000/uL
D. Albumin > 3.5 g/dL

Answer 258

C. Platelet 90,000/uL

Question 259

Patient EG came to the ER due to dizziness, dyspnea and generalized wheals after running 5km running in treadmill. He claimed that he ate muffins for his lunch before running. Which of the following allergens is most commonly implicated in exercise-induced anaphylaxis?
A. Eggs
B. Milk
C. Wheat
D. Peanuts

Answer 259

C. Wheat

Exercise-induced anaphylaxis can be precipitated by exertion alone or can be dependent on food ingestion prior to exercise. There is an association with the presence of IgE specific for α-5 gliadin, a component of wheat.

Question 260

40-year-old female was recently diagnosed with hypertension and was started with Enalapril. She complained of periorbital edema and dyspnea. What is the pathophysiology of her condition?
A. Impaired bradykinin degradation
B. Mutation in SERPING1 gene
C. Binding of IgE to human mast cells and basophils
D. Generation of bradykinin in the setting of C1 inhibitor (C1INH)

Answer 260

A. Impaired bradykinin degradation

Angioedema without urticaria can be idiopathic or due to the generation of bradykinin in the setting of C1 inhibitor (C1INH) deficiency that may be inborn as an autosomal dominant mutation or may be acquired through the appearance of an autoantibody in the setting of malignancy or autoimmune disease.

The angiotensin-converting enzyme (ACE) inhibitors can provoke a similar clinical presentation in 0.2–0.7% of exposed patients due to delayed degradation of bradykinin. Black race, organ transplant, female gender, smoking, and increasing age are known risk factors for ACE inhibitor–related angioedema

Question 261

35-year-old female was diagnosed with urticaria. She
was given cetirizine 10 mg ODHS but noted to have
persistent urticaria. What is the next best step of
action?
A. Add montelukast 10 mg OD
B. Add famotidine 20 mg OD
C. Increase dose of cetirizine
D. Shift to levocetirizine

Answer 261

C. Increase dose of cetirizine

For most forms of urticaria, H1 antihistamines effectively attenuate both urtication and pruritus; long-acting, non sedating agents, such as loratadine, desloratadine, and fexofenadine, or low-sedating agents, such as cetirizine or levocetirizine, generally are used first and can be increased to up to four times daily dosing.

Question 262

A 40-year-old male complains of recurrent nasal congestion and postnasal discharge when exposed to cold environment. You diagnosed him with vasomotor rhinitis and started with olopatadine. What adverse effect of the medication should you tell your patient to watch out for?
A. Dysgeusia
B. Insomnia
C. Glaucoma
D. Urinary retention

Answer 262

A. Dysgeusia

The nasal antihistamines azelastine and olopatadine may benefit individuals with nonallergic vasomotor rhinitis as well as have additive benefit to intranasal steroids in allergic rhinitis, but they have an adverse effect of dysgeusia (taste perversion) in some patients.

Question 263

The typical skin lesion seen in patients with serum sickness or serum sickness like reaction
A. Small blisters form from dusky macules
B. Diffuse red morbilliform eruption
C. Purpuric eruption along sides of hands and feet
D. Swelling of central face

Answer 263

B. Diffuse red morbilliform eruption

A - Steven Johnson Syndrome
B - Drug-induced hypersensitivity syndrome
C - Serum sickness or serum sickness-like reaciton
D - Angioedema