CIS Flashcards
Wickham striae and lichen planus
pruritic, purple, polygonal, planar, papules, and plaques
associated with Hep C
seboerreic keratosis-
never need to biopsy
white things coming out
What structure is most likely to have a different appearance in axillary skin?
Eccrine/apocrine sweat glands
Spongiosis seen in eczematous dermatitis develops in which area?
Stratum spinosum
Allergic atopic
“spongiotic dermatitis”
food, insect, light, drug, allergen testing
humoral mediation type I*
eosinophils prominent in inflammation
responds to topical steroids
history to differentiate from allergic contact
- family history of eczema, hay fever or asthma
Allergic contact “spongiotic dermatitis”
poison ivy, nickel, other metals, rubber compounds
T-cell mediated type IV*
lymphocyte rich inflammation
Will not respond to topical steroids
no inflammation until 2nd exposure; > 24 hr delay
Often topically applied antigens
Primary irritant “spongiotic dermatitis”
chemicals
no prior exposure as direct damage to epidermis
necrosis and ulceration with neutrophil response
- localized mechanical or chemical irritants (nonimmunologic)
drug-related eczematous dermatitis
- infiltrate ofen deeper with *abundant eosinophils
Temporal relationship to drug administration
photoeczematous eruption “spongiotic dermatitis”
occurs at sites of sun exposure, may require associated exposure to systemic or topical antigen
eczematous insect bite reaction
spongiotic dermatitis
wedge-shaped infiltrate; many eosinophiles
A 25 y/o female has been using lip balm continuously for months and the changes seen in the image are not improving. Presumptive dx? what to do?
Presumptive Diagnosis?
Allergic or irritant contact exfoliative cheilitis
What to do?
Stop using the lip balm and substitute moisturizer with limited ingredients and/or topical corticosteroid. Could consider cultures for S. aureus or C. albicans.
A 34 year old female developed a pruritic rash that involved the skin. Her dentist also noted bluish and reddish white lesions in the mouth.
Wickham striae and lichen planus
Topical steroids were used to control itching
and problems resolved after a few months.
Test to order for definitive diagnosis?
None, biopsy can be done for difficult cases.
What clinical entities are associated with this disorder and what is the pathophysiology?
Hepatitis C, ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosis and myasthenia gravis
It is a cell-mediated immune response of unknown origin.
Atrophy of which structure leads to “dry skin”?
Sebaceous gland
old skin?
Aging and chronic actinic skin damage
Sunburn
acute inflammation with pain, desquamation, blistering with secondary infections, chronic actinic skin damage including wrinkles, solar elastosis, solar lentigos, actinic keratoses, squamous cell carcinomas, basal cell carcinomas and melanomas
A 52 year old male presents with a new skin rash not responding to topical cortisone and moisturizers. During the physical examination the rash is diffuse and there is also axillary and cervical lymphadenopathy. Presumptive dx?
Presumptive Diagnosis?
Ichthyosis
What subtype?
** Ichthyosis vulgaris (autosomal dominant or acquired)
other types:
Acquired associated with hypothyroidism, sarcoidosis, lymphoma, visceral or generalized cancer, HIV or medications (e.g. nicotinic acid and hydroxyurea)
Congenital ichthyosiform erythroderma (recessive)
Lamellar ichthyosis (recessive)
X-linked ichthyosis
Test(s) to order for definitive diagnosis?
Search for underlying etiology and continue
topical treatment until underlying cause
is found and treated - CBC with diff, lymph node biopsy in this case of probable lymphoma
Newborn with blistering skin disease. Presumptive Diagnosis?
Epidermolysis bullosa
Supportive care with treatment of infections and contractions as they occur
Test to order for definitive diagnosis?
Skin biopsy to exclude other blistering disorders and electron microscopy to sub-classify the disease if epidermolysis bullosa is the diagnosis
I. Simplex type: keratin 14 or 5 mutation
Intraepidermal (suprabasilar) blisters
II. Junctional type: defect at lamina lucida (laminin or BPAG2 defects)
Intra-lamina lucida subepidermal blisters
A 14 year old female presents with a chronic skin rash. Presumptive Diagnosis and treatment?
Acne vulgaris Rx- 1. Benzoyl peroxide 2. Erythromycin or clindamycin 3. Topical retinoids - Be careful with retinoids in child-bearing age females as they may be potentially teratogenic in topical forms and definitely teratogenic in oral forms (affects HOX gene expression leading to neural crest migration craniofacial defects and also increased abortions)
Structures involved and need for further testing?
Pilosebaceous gland – no further testing needed (classic clinical presentation)
Factors important in development of acne?
Plugging of the hair follicle with desquamated cells
Sebaceous gland hyperactivity (begins at puberty with influence of testosterone)
Proliferation of bacteria (especially Propionibacterium acnes)
Inflammatory response to bacteria & entrapped keratin
Difference in comedo in whitehead vs blackhead?
Superficial oxidized sebum
What is the difference in presentation of a papule vs a pustule and what occurs in the pilosebaceous unit to lead to a pustule?
Papule is dome shaped skin elevation that can occur in blackheads or whiteheads without pus.
Pustule occurs when skin pore is blocked and accumulated infected debris is accompanied by purulent material.
Pile of lumps on scalp. Tumor Type and Cell of Origin?
Turban tumor (cylindromas)
basal cell carcinoma 5-year prognosis?
Excellent, expect almost 100% survival
What are the gross clinical criteria for melanoma?
Asymmetry
Irregular Borders
Uneven Color
Diameter >6mm
Melanoma Poor Prognostic Indicators
#1 Breslow level (thickness) Tumor ulceration Nodal metastases (sentinel node biopsy)
Distant metastases (visceral mets are worse)
Lactate dehydrogenase elevation
Location (head and neck worst, palmar and plantar bad)
High mitotic activity Lack of tumor infiltrating lymphocytes Older age (>65 worse) Male sex (for younger people) High tumoral vascularity (angiogenesis) Satellitosis Tumor regression
Ataxia-telangiectasia
familial cancer syndrome- ataxia, dyskinesia and vascular telangiectasias of conjunctiva and skin
Nevoid basal cell carcinoma
= Gorlin syndrome
multiple basal cell carcinomas; odontogenic keratocysts, palmar and plantar pits, medulloblastomas and ovarian fibromas; calcifications of falx cerebri
Cowden syndrome
benign follicular appendage (trichilemmomas) tumors; hamartomatous colon polyps; internal adenocarcinoma (often breast/ endometrium); cerebellar dysplastic gangliocytoma
Muir-Torre syndrome
mismatch repair
sebaceous adenoma, sebaceous epithelioma, or sebaceous carcinoma and a visceral malignancy (usually gastrointestinal or GU carcinomas)
Neurofibromatosis 1
neurofibromas (plexiform and solitary), optic nerve gliomas, Lisch nodule on iris; cafe au lait spots
Neurofibromatosis 2
neurofibromas, meningiomas and bilateral acustic neuromas; spinal cord ependymomas
Tuberous sclerosis
hamartomatous brain tumors; mental retardation; renal angiomyolipomas; retinal hamartomas; pulmonary lymphangioleiomyomatosis; cardiac rhabodmyomas
A 71 year old male with multiple yellowish nodules on the scalp and forehead. The patient has a history of adenocarcinoma of the colon. Presumptive Diagnosis of lesion and syndrome?
Sebaceous tumor – specifically sebaceous adenoma, arising in patient with Muir Torre Syndrome
A 66-year-old male patient presented with multiple asymptomatic skin lesions and a history of recurrent basal cell carcinoma. Also present are exophthalmos and numerous pits over the palms and soles. Surgical procedures for the basal cell carcinoma took place 12 and 6 years ago. Biopsy of the mass and a lung nodule demonstrated basaloid squamous cells.
Presumptive Diagnosis of lesions and syndrome?
Nevoid basal cell (Gorlin) syndrome with recurrent and metastatic basal cell carcinoma
Tests to order for follow up?
X-rays of skull, vertebra and jaws to look for calcified falx cerebri, odontogenic keratocysts, malformations of vertebrae
Mutated genes and additional neoplasms that may arise?
PTCH or SMO
Ovarian fibromas and cerebellar medulloblastomas
Gorlin Syndome
Random basal-cell tumors have mutations in the hedgehog signaling pathway that either
1- inactivate PTCH1 [7-9] (loss-of-function mutation)
2- constitutively activate SMO15 (gain-of-function mutation)
Basal Cell Carcinoma- Increased incidence in genetic syndromes
Albinism
Xeroderma pigmentosa
Nevoid basal cell carcinoma syndrome (Gorlin syndrome)
34 year old male presents to your office with a long history of pigmented skin lesions but one has been changing. Presumptive Diagnosis?
Melanoma arising in dysplastic nevus syndrome
Test to order for definitive diagnosis?
Intact excisional biopsy of the worrisome lesions. Continue surveillance of all other lesions.
42 year old from North Carolina who likes to bird hunt presents with fever, rash and abdominal pain for a few days. Felt fine previously. His hunting dogs also not feeling well and he has been treating them for ticks.
Presumptive Diagnosis?
Petechial rash of Rocky Mountain Spotted Fever
Patient started on Doxycycline
Two ticks that carry R. rickettsii
Rocky Mountain wood tick - Northwest
American dog tick - pacific coast, eastern and central USA
lyme disease treatment and dx test?
Patient started on Doxycycline
Test to order for definitive diagnosis?
Enzyme-linked immunosorbent assay (ELISA) or immunofluorescence assay (IFA) with Borrelia burgdorferi antigen
vector for lyme disease
deer tick
Male who raises bees is brought to the emergency room by his friend. Bee keeper had marked itching of the face and abdominal discomfort. He had reacted to bee stings before but not as much. Shortly after arrival he became unresponsive and was noted to have a fast pulse rate.
Presumptive Diagnosis and treatment
Anaphylactic Reaction to Hymenoptera stings
Start epinephrine, steroid, antihistamine and H2 blocker.
Search bite sites to remove stingers (diminish antigen)
Test to order for definitive diagnosis?
A young child developed swollen lips and tongue after eating a ham sandwich at a restaurant. The child had previously had localized reactions to latex.
Presumptive diagnosis and immediate treatment?
Latex allergy
Start patient on liquid Benadryl (diphenhydramine) and Tagamet (cimetidine)
(purchase at nearby pharmacy/grocery store if epinephrine is not readily available
Test to order for definitive diagnosis?
None, contact testing for this degree of reaction may lead to anaphylactic shock.
Trombiculosis = Chiggers
Larvae of red mites or harvest mites
Attach to skin of ankles, waistline, armpits and perianal area after the host walks through a grassy environment
They pierce skin near a hair
follicle and feed on partially
digested skin cells then drop off the host
The host reacts to the mite saliva
with intense itching.
