Exam

Question 1

True or False?

• is commoner in men?
• may be treated with methotrexate?
• may cause finger clubbing?
• never starts in infancy?
• rarely itches?

Answer 1

pink scaly plaques, particularly on the exterior surfaces, which may become itchy and sore.

1. Psoriasis affects males and females equally
2. first line treatments are emollients, topical steroids, calcipotriol, retinoids and purified coal tar.

• if resistant use of phototherapy or systemic therapy like methotrexate once weekly.

1. clubbing is not a feature of psoriasis
2. psoriasis can start in infancy although there are two peaks of ages of onset, early (16-22) and late (55-60).
3. it does often become itchy.

Question 2

A 30 year old women with a long history of plaque-like lesions on the exterior aspects of her elbows, and also pitting of her nails?

Answer 2

Psoriasis:

• tenfold increase in the speed of epidermal cell proliferation in psoriasis
• pitting of nails and onycholysis is characteristic of this disease.
• Different classifications:
  
  • Guttate psoriasis
  • Plaque psoriasis
  • Flexural psoriasis
  • Pustular psoriasis
  • palmar and plantar psoriasis

Question 3

A 45 year old man with a one year history of pruritus. Examination shows widespread excoriations with vesicles, most of which are ruptured. He has a raised titre of anti-tissue transglutaminase antibodies.

Answer 3

Dermatitis herpetiformis

• dermatitis herpetiformis mainly occurs between 20-50 years and is always associated with coeliac disease
• large pruritic lesions
• immunofluorescence shows IgA deposits in unaffected skin
• treatment is gluten free diet and dapsone.

Question 4

A 72 year old woman complains of a six month history of tense blisters forming over the trunk and lower limbs. There are no lesions in the mouth.

Answer 4

Pemphigoid

• site of blister is at the basement membrane between dermis and epidermis (pemphigus is in epidermis). Therefore blisters are less likely to rupture
• mucosal lesions are unlikely
• biopsy would show IgG and complement in basement membrane zone.
• treatment is systemic steroids and azathiprine for steroid sparring.

Question 5

A 23 year old women with severe sore throat and painful, raised red lesions on her shins.

Answer 5

Erythema Nodosum

• acute panniculitis (inflammation of subcutaneous adipose tissue) that produces painful nodules on the shins
• streptococcal throat infection is the cause in this case.

Question 6

A 40 year old women with elevated skin lesions with a peau d’orange appearance over her lower legs. History of thyroidectomy. Examination revealed exophthalmos.

Answer 6

Pretibial Myxoedema

• occurs in about 5% of patients with Graves Disease
• superficial layer is infiltrated with hyaluronic acid

Question 7

40 year old white women, a travel courier, notes a painless lesion on her calf. Lesion is brown, irregular margins, measuring 1.5cm in diameter. The lesion is itchy, and she complains that is has bled.

Answer 7

• classic malignant melanoma
• pigmentation, increasing size, bleeding, itchiness.

Question 8

A 29 year old man, working as a journalist, with a history of HIV infection presents with a cluster of pearly-like lesions each 0.3cm in diameter around the beard.

Answer 8

molluscum contagiosum

• benign DNA pox virus.
• Cell mediated immunity is important for modulating and controlling the infection
• children and HIV-infected patients have more widespread lesions.

Question 9

A 35 year old, Afro-Caribbean origin. Wants excision of a firm nodule over the sternum, stating she had previous surgery there.

Answer 9

Keloid Scarring

• common in Afro-Caribbean origin.
• Benign overgrowth of fibroblastic tissue.
• Appear on upper back, chest, deltoid region and follow skin injury.

Question 10

75 year old builder, presents with white lesion on the cheek. Has central ulcer 0.5cm in diameter, with rolled edges and adjacent telangiectasia. Lesion has been present for 3 months.

Answer 10

Basal cell carcinoma

• typically slow growing, rolled edges, occur on the face, associated with telangiectasia.
• increase with advancing age.

Question 11

16 year old boy with scaly patches on his scalp. Examination reveals well-circumscribed areas of hair loss, 2-5cm in diameter with scaling and raised margins. There is no scarring.

What is the likely cause?

Answer 11

Tinea Captis

• non-scarring alopecia due to invasion of hairs by dermatophytes (trichophyton tonsurans)
• most common cause of alopecia include:
  
  • telogen effluvium
  • androgenic alopecia
  • alopecia areata
  • tinea capitis
  • traumatic alopecia
• less common are:
  
  • SLE
  • secondary syphilis
• scarring alopecia is more common in primary cutaneous disorders, e.g. lichen planus, folliculitis decalvans, cutaneous lupus or linear scleroderma (morphea)

Question 12

50 year old man presenting with itching and blistering of the hands and forehead. On examination there are small excoriated areas on the backs of his hands.

What is the likely diagnosis?

1. dermatitis herpetiformis
2. SLE
3. pemphigoid
4. pmphigus
5. porphyria cutanea tarda (PCT)

Answer 12

PCT (porphyria cutanea tarda)

• photosensitive element to the distribution
• both SLE and PCT are related to this however its more typical of PCT
• PCT causes blistering which usually heal with small scar and milia formation
• associated with excessive alcohol intake but can be inherited.

Question 13

A 40 year old male had multiple blisters of the trunk and extremities. Direct immunofluorescence studies showed linear IG deposits along the basement membrane.

What is the likely diagnosis?

1. Bullous pemphigoid
2. dermatitis herpetiformis
3. pemhigus foliaceus
4. pemphigus vulgaris

Answer 13

a - bullous pemphigoid

• tense bullae, fluid filled with normal or erythematous skin.
• occurs at a subepidermal level, deeper than the blisters of pemphigus vulgaris (occurs at the dermal-epidermal junctuion)
• in bullous pemphigoid there is linear basement membrane zone depostion - there are IgG type
• pemphigus has thin walled fragile blisters
• skin biopsy for routine and direct immunofluorescence is needed to differentiate from bullous pemphigoid.
  *

Question 14

A 55 year old man has been aware of these lesions developing over the lower limbs for the last couple of week:

What is the likely diagnosis?

1. dermatitis herpetiformis
2. erythema multiforme
3. henoch-schonlein purpura
4. pemphigoid
5. shingles

Answer 14

d - pemphigoid

• typically bullous lesions are on the lower limb.

Henoch-Schonlein purpura causes purpuric rash

Erythema multiforme is associated with ‘target lesions’

Herpes zoster or shingles causes vesicular eruption in a dermatomal pattern.

Dermatitis herpetiformis is associated with coeliac disease and typically has pruritic vesicular lesions on the rump.

Question 15

A 6 month baby presents with one day history of fever (39) and a generalised rash, which began n the legs and is now on the limbs/trunk. Its purplish, non-palpable, and non-blanching.

Whats the Diagnosis?

1. giant urticaria
2. haemophilia
3. henoch-schonlein purpura
4. measles in the mild form
5. meningococcal septicaemia

Answer 15

e - meningococcal septicaemia

• causes generalised nonblanching purpuric eruption

Giant urticaria - recurring attacks of transient oedema appearing in areas of skin or mucous membranes.

Measles rash starts about 14 days after exposure, generalised macular eruption on the face, neck and spreads over three days.

Haemophilia is not associated with rash.

HSP would not present with a high fever in an acutely unwell child. It is more likely subacute.

Question 16

A 60 year old man presents to GP wtih 3 months of proximal muscle weakness. There is a barely perceptible purple rash on sun exposed areas, but more noticeable over the knuckles.

He was a smoker of 20 cigarettes a day for 40 years.

What is the diagnosis?

1. Cushing’s syndrome
2. dermatomyositis
3. ectopic parathyroid hormone production
4. myotonic dystrophy
5. polymyalgia rheumatica

Answer 16

b - dermatomyositis

dermatomyositis is an autoimmune disease characterised by polymyositis and skin rash.

• classic purple (helitrope) rash is seen on sun-exposed areas and may be pruritic
  
  • eyelids
  • nose
  • cheeks
  • forehead
  • knees
  • knuckles
  • nail beds
• older patients presenting for the first time an underlying malignancy should be considered. Lung, ovary, breast and gastrointestinal are common. (often bronchial neoplasia). CXR and CPK appropriate Ix.
• other associated conditions are scleroderma and mixed connective tissue disease (anti-Jo-1 antibodies might be present)
• EMG should demonstrate low amplitude, short duration, polyphasic potentials.
• biopsy is useful to determine the types/specific antibodies.
• common other clinical signs?
  
  • clubbing
  • lymphadenopathy
  • RA
  • Raynaud’s phenomenon
  • cachexia
  • calcinosis
  • dilated capillary loops on the base of nails
  • Gottron’s patches (red scaly papules that appear on finger joints, knees and elbows)

Question 17

Alopecia in children is recognized in which of the following conditions?

1. Alopecia areata
2. Ectodermal dysplasia
3. Naevus flammeus
4. Ringworm
5. Trichotillomania

Answer 17

1. True - alopecia is the autoimmune destruction of hair follicles
2. True - ectodermal dysplasia is characterised by absent or deficient function of at least two of the ectoderm derivatives. e.g. hair and teeth.
3. False - naevus flammeus is given to a port-wine stain.
4. True - Ringworm results in hair loss
5. True - trichotillomania is the impulsive need to pull out hair from the scalp.

Question 18

64 year old man, GP with itchy red brown lesion on the cheek. Slow growing, 1x0.5cm lesion with a crusty surface. No other lesions are seen. No lymphadenopathy.

Answer 18

Bowen’s Disease

• premalignant lesion for SCC.
• UV exposure is the main RF
• often small foci of SCC within it so should be treat as an SCC

Question 19

A 45 year old woman is referred with a lesion on her cheek. Raised above the level of the surrounding skin, has irregular surface with smooth sides, central umbilication with a crusty core.

Answer 19

Keratoacanthomas

• benign lesions often mistaken for BCC/SCC.
• hyperplasia of hair follicles in sun exposed areas
• regress spontaneously over a period of 6-12 months.

Question 20

70 year old woman is referred with 3x2cm pigmented brown-black lesion on her right temple. On examination the lesion has an irregular edge but has a smooth flat surface. No lymphadenopathy palpable.

Answer 20

Lentigo maligna (aka Hutchinson’s freckle)

• occurs in sun exposed areas more common in females
• a melanoma in situ
• has a good prognosis than other more common melanomas

Question 21

a 34 year old IVDU seen with several new red-brown nodules on his limbs. He is also being treated for pneumonia with an opportunistic infection. AZT is on his prescroption.

Answer 21

Kaposi’s sarcomas

• common manifestation of HIV infection may be the presenting feature
• no treatment needed but the lesions improve with ART.

Question 22

A 53 year old man seen in the ED with haematemesis. Hepatosplenomegaly, clubbing and multiple small red lesions over his torso that blanch with pressure and then fill from the centre outwards.

Answer 22

Spider naevi

• a form of telangiectasia and occur in the general population on the torso and head/neck.
• 5 or more are present they are considered pathological and often associated with chronic liver disease.
• no treatment - investigate the liver.

Question 23

Spot the Diagnosis from this picture

Answer 23

• pruritic vesicular rash
• calamine lotion
• not in a dermatomal distribution

Question 24

A 17 year old male presented with polyuria, this penile rash and a 2 month history of weight loss. What Ix is most appropriate?

1. Plasma glucose
2. HIV test
3. Urethral swab and culture
4. Urine culture
5. VDRL

Answer 24

• A - shows balantis often the presenting feature of DM due to candida infection.
• history of weight loss would be confirmed by fasting plasma glucose above 7mmol/L

Question 25

A young child is seen with peeling of the palms of the hands and the soles of the feet. Which of the following is a potential explanation for this presentation?

Answer 25

• Kawasaki disease
  
  • acute vasculitis of medium sized vessels, which classically involved the coronary arteries
  • presence of a fever for more than 5 days with mucocutaneous changes and lymphadenopathy
  • esquamation of the fingers and toes begins in the periungual region, may involve the palms and soles. Usually is observed one to two weeks after the onset of fever.

Question 26

Rash that begins on the head and spreads to the trunk and extremities over a few days. Lasts at least 3 days. Fades in order of appearance. Brownish discolouration can be left behind with confluence over the buttocks.

Answer 26

Measles

Question 27

What is the presentation of someone with Tuberous sclerosis in terms of skin?

Answer 27

• ash-leaf macules with discrete areas of hypopigmentation often present at birth
• Shagreen patch in the form of a rough patch of skin similar to shark skin texture
• adenoma sebaceum which is angiofibromas of the face.
• fibromas may also develop within the CNS and calcify in the periventricular area
• genetic condition causing benign adenoma formation in internal organs and on the skin.

Question 28

A 72 year old lady presenting with dysphagia. Which of the following autoantibodies is highly specific for this condition?

1. Anticardiolipin antibody
2. Anticentromere antibody
3. Antimitochondrial antibody
4. Antinuclear factor
5. Rheumatoid factor

Answer 28

Systemic Sclerosis/CREST

• anticentromere antibody is the strongest associated with CREST syndrome
• RF is non-specific and is positive in 25% of cases, ANF is 95% positive
• ANA and anti0U3 nucleolar RNP is strongly specific
• anticentromere antibodies strongly associated with CREST syndrome are anti-SSA (Ro) and anti-SSB (La) antibodies seen in SSc and associated with Sjogren’s syndrome
• Anticardiolipin found in SLE.
• Antimitochondrial is with primary biliary cirrhosis
• Anti-RNP antibodies also associated with mixed connective tissue disease.

Question 29

A 64 year old asylum seeker has arrived in the UK with painless lesion on his forearm. It started as a small red itchy lesion which then blistered bursting to form the lesion shown. He was employed as a sheep herder.

Answer 29

• cutaneous anthrax
  
  • an infection of the skin bacillus anthracis.
• in the axilla you may see lymphadenopathy
• Professions associated:
  
  • animal hair or hides
  • bone products
  • wool or infected animals
• treatment:
  
  • penicillin
  • ciprofloxacin
  • doxycyclin
• bioterroism and potential use of anthrax spores

Question 30

Which of these is associated with Erythema Nodosum?

1. Paracetamol
2. Leprosy
3. Tuberculosis
4. Sarcoidosis
5. Streptococcal infection

Answer 30

1. paractamol - false
2. leprosy - true
3. TB - true
4. Sarcoidosis - true
5. Streptococcal infection - true

others:

• yersinosis
• UC
• COCP and sulphur containing antibiotics

treatment is NSAIDs

Question 31

Sebaceous Cysts which of the following are true or false?

• a central punctum is a common feature T/F
• the scalp is a common location? T/F
• they arise in the dermis? T/F
• they contain mucopolysaccharides? T/F
• they are tethered to the skin? T/F

Answer 31

• T
• T
• T
• F
• T

they have a central punctum - a central point

they are dermal and fluctuance within the dermis, with sebaceous material. May become acutely infected with local inflammation.

Question 32

Which of the following and true and false regarding squamous cell carcinoma?

• It is comoner malignant skin tumour than BCC
• it is the most common skin tumour seen in transplant patients
• It only occurs in the skin
• metastasis is usually to regional lymph nodes
• the tumour can have everted edges

Answer 32

• F
• T
• F
• T
• T

BCC is more common, but SCC is more common in immunocompromised transplant subjects. SCC also occur in the lung, cervix and oesophagus.

often have an everted edge.

Question 33

1. A 29 year old women develops itchy scaly rash over wrists and fine white streaks overlying lesions. Her buccal mucosa is lined with lacy, white pattern.
2. 20 year old man with recent onset itching, following viral infection. There is whealing of the skin after he has scratched it, which can last up for an hour.

Answer 33

1. lichen planus - caused by drugs (thiazides, quinidine, antimalarials, beta-blockers) or graft versus host disease
2. urticaria - transient swelling of the skin, caused by vasodilation and accumulation of tissue fluid in the dermis.

Question 34

Look through these case sceanarios and choose the most appropriate treatment in each:

1. A 17 year old female presents with troublesome facial acne with mild hirsutism. Recently diagnosed with PCOS.
2. A 55 year old male presents with redness of both cheecks with extensive papules. He is diagnosed with acne rosacea.
3. A 15 year old girl presents with troublesome facial acne which tends to be worse around the time of her periods. There is mild acne around her chin and cheeks.

Answer 34

1. Dianette - COCP for PCOS, cyproterone acetate has antiandrogenic actions reducing sebum production plus helping with hirsutism
2. Oral tetracyclines
3. Topical benzoyl peroxide

treatment of mild to moderate acne vulgaris is best started with topical benzoyl peroxide.

acne rosacea - LT therapy is best with tetracyclines.

Question 35

A 27 year old sexually active male develops a single vesico-bullous lesion on the glans penis soon after taking paracetamol for a headache. The lesion quickly healed with some associated hyperpigmentation. Which of the following is the diagnosis?

1. Behcet’s syndrome
2. Fixed drug eruption
3. Herpes genitalia
4. Pemphigus vulgaris

Answer 35

Fixed Drug Reaction

sexual activity is a red herring:

• paracetamol prior
• the classical site
• healing of lesion with hyperpigmentation

once sensitised he will develop a blistering reaction at the same site every time. Antigenic binding of the drug at the site eliciting an autoimmune reaction. Other sites can be involved. Other drugs:

• tetracyclines
• NSAIDs
• benzodiazepines
• quinine

Question 36

This 55 year old patient presented with a four month history of nausea and weight loss (8kg). He is complaining of vague abdo discomfort with no clear exacerbating factors. He had a partial gastrectomy 20 years previously for a gastric ulcer. He was not taking prescribed medications.

Answer 36

Acanthosis nigricans

• hyperpigmented velvety surface
• occurs in axillae, groins and skin folds and occasionally on the dorsum of the hand
• its associated with
  
  • endocrine disease (Cushings, acromegaly, insulin resistant DM)
  • PCOS
  • paraneoplastic phenomenon (usually GIT tumous, especially adenocarcinoma of the stomach).

Question 37

A 25 year old female with concerns regarding toe nails. Whitish discolouration extending up to the nailbed with a number of toes. Entirely painless and she is otherwise well.

What is the treatment?

1. Oral fluconazole
2. Oral terbinafine
3. topical benzoic acid
4. topical fluconazole
5. topical terbinafine

Answer 37

B - oral terbinafine

• fungal nail infection (onychomycosis)
• topical antifungals may be effective for one or two but not when there are a number of nails affected.
• therapy is slow and may be needed for 6 months
• terbinafine is recommended because effective against both dermatophytes and candida species
• fluconazole not super effective against dermatophytes.

Question 38

A 22 year old man comes in with redness and itching on his face and hands. He regularly visited another GP with similar complaints within the last two years and has been signed off as sick leave for builder employment. Receipt of benefits and insurance claims for loss of earnings. Ointment cured the problem.

Exam shows no lesions. He does not seem worried. What is the likely diagnosis?

1. conversion
2. delusional disorder
3. malingering
4. munchausen syndrome
5. OCD

Answer 38

D - malingering - conciously fakes or claims to have a disorder in order to attain a specific gain.

Maunchausen’s syndrome is manifested by a chronic history of multiple hospital admissions and willingness to recieve invasive procedures

Question 39

What does this picture show with a history of weight gain, tiredness, and feels cold?

What other conditions could cause this?

Answer 39

Vitiligo

• a condition of localised hypomelanosis due to autoimmune destruction of melanocytes. Classically affects the periorifacial, trunk and extensor surfaces.
• diseases of the thyroid occurs in up to 30% of patients with vitiligo.

Answer here:

• autoimmune hypothyroidism

Other things associated with this condition?

• graves disease
• pernicious anaemia
• addison’s disease
• alopecia areata

Question 40

Diagnose the following Sceanarios:

1. 3 year old girl macular confluent rash which appeared initially behind the ears. 5 days previously she had a low grade fever, catarrh (build up of mucus) and conjunctivitis. Mother is vague about immunisation history.
2. 2 year old boy in hospital with vomiting, non-bloody watery diarrhoea, and dehydration. Other children have similar.
3. 2 year old boy is mildly unwell, vesicles in mouth, palms and soles of feet.
4. 10 year old girl develops itchy rash on trunk and spreads to the entire body. Travelled to see her grandmother who had a painful rash 3 weeks ago.
5. 4 month old baby daughter of a HIV + mother admitted with seizures. Neonatal jaundice and microcephaly.

Answer 40

1. Measles
   
   • RNA paramyxovirus
   • transmitted by droplets and incubation is 10-21 days.
   • prodromal is 3Cs + K - conjunctivitis, coryzal and cough, with Koplik’s spots (bright red lesions with central white dot which appear on buccal mucosa). Koplik spots are diagnostic.
   • viral culture from leisons and 4x rise in abtibody titres
   • OM, pneumonia, meningitis and SSPE (subacute, sclerosing pancencephalitis) occurs.
2. Rotavirus
   
   • viral gastroenteritis
   • fecal oral route - aged between 6mths to 6 years
   • RNA replicates in intestinal mucosa leading to salt and water depletion.
   • culture from stools and PCR techniques
   • rehydration therapy and correcting electrolytes.
3. Coxsackie Virus
   
   • cocksackie A16 causes hand, foot and mouth disease
   • fever, sore throat and vesicles on palms, oropharynx and on the soles.
   • Incubation period is 5-7 days without crusting.
4. Varicella
   
   • respiratory droplet transmission and contact with someone with shingles.
   • Incubation period is 14-21 days
   • itchy papulovesicular rash on trunk and spreads to the head and extremities
   • antiviral therapy is reserved for systemic disease and immunocompromised
5. CMV
   
   • CMV inclusion disease results of infection of the fetus.
   • microcephaly, seizures, neonatal jaundice, deafness and mental retardation

Question 41

Suggest the appropriate treatments for each sceanario:

1. An aspiring pop musician presents with erythematous papules and nodules on the face, chest and upper back. Also notice some cysts and scarring
2. A 60 year old women with a 5 year history of psoriasis has been admitted for treatment 3x in the last 8 months. Very ill and febrile and 90% of her skin is fiercely ill and scaly.
3. 7 year old girl brought to see you because she had mild red patches in cubital and popliteal fossae. Her mother is asthmatic.
4. A women with a large red patch over her cheek and lower jaw, which she has had since infancy.
5. A women of welsh descent presents with hyperpigmented swelling on her right leg. She is concerned it has doubled over the past two months.

Answer 41

1. Isotretinoin (Roaccutane)
   
   • standard treatment for severe acne
   • teratogenic and a pregnancy test and use of contraception is mandatory in women
2. Methotrexate
   
   • bland topical treatments also can be used
   • systemic supportive therapy and antibiotics
3. Emollients
   
   • atopic dermatitis and all patients require emollients
4. Laser therapy
   
   • port wine stains with a high success rate
   • can also be used for hemangiomas, telangiectasia, spider naevi and tattoos
5. Surgical excision - Wide
   
   • malignant melanoma related to the depth of tumour invasion.
   • adjuvant treatment may be needed.

Question 42

52 year old man with T2DM and 2 days of pain in the left leg, swelling and fever. He tells you he is allergic to penicillins as that produced a rash previously.

On examination he has a temp of 39 degrees. See pic below:

What is the appropriate IV treatment?

1. clarithromycin
2. co-amoxyclav
3. flucloxacillin
4. gentamicin
5. metronidazole

Answer 42

Cellulitis - A - clarithromycin

• diabetics are susceptible to infection
• staph aureaus or GBS flucloxacillin is the most appropriate, but the allergy means you use clarithromycin.

Question 43

28 year old man in hospital as he is increasingly breathless. Dry cough and expectoration of bright red blood. History of malaise and low grade fever for 5 days. The rash is pictured below.

What is the treatment?

1. co-amoxiclav + clarithromycin
2. high dose corticosteroids
3. IV acyclovir
4. IV benz pen + flucoxacillin + ethambutol
5. rifampicin + isoniazid + pyrazinamide + ethambutol

Answer 43

• IV acyclovir
• varicella pneumonia occurs in 20% adults with chickenpox.
  
  • tachpnoea
  • cough
  • dyspnoea
  • fever
• cyanosis, pleuritic chest pain and haemoptysis are common

Question 44

Early 20s this man had haemoptysis. He has required intermittent blood transfussions throughout his life. What is the diagnosis?

Answer 44

• hereditary hemmorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
  
  • inherited AD trait (but also sporadic)
• presents in early adult life with anaemia due to occult bleeding
• complications
  
  • haemoptysis
  • pulmonary haemorrhage
• lesions commonly on the face.

Question 45

A 40 year old man presents with polyuria and impotence. On examination the liver is palpable three finger breadths below the costal margin. Picture shows the man’s back.

Ix show elevted serum iron and transferrin saturation and a reduced iron-binding capacity.

What is the condition in the picture?

What is the diagnosis?

What is the Treatment?

What other rheum conditions are associated with the skin condition?

Answer 45

• excessive melanin deposition
• hereditary haemochromatosis
• pseudogout is associated
• repeated venesection (desferrioxamine)

Triad of:

• hepatomegaly
• DM
• bronze pigmentation.

Question 46

A 56 year old gentlemen presents to his GP for a four month history of muscle weakness and soreness of muscles which he describes as tender to touch.

Having difficulty climbing stairs and rising from his chair.

Rash on the back of his hands.

What is the diagnosis?

Ix to confirm the diagnosis?

Two treatments?

List one condition frequently underlying this disorder?

Answer 46

• dermatomyositis
  
  • progressive muscle deterioration which fluctuates in severity from mild to severe.
• a muscle biopsy, but also Anti-Jo 1 autoantibodies and CPK
• treatments:
  
  • oral steroids and prednisolone
  • immunosuppressants (methotrexate)
• malignancy, breast, lung, colon cancer.

Question 47

An otherwise asymptomatic 38 year old man presents to GP having raised reddish non-pruritic lesions on the elbows. In the history he mentions both his father and grandfather died of heart attacks at 49 and 53 respectively.

What are these skin lesions?

What is the most likely diagnosis?

Name one investigation that would confirm this?

How would you treat this patient?

Answer 47

• tendon xenthomas
  
  • raised levels of lipoproteins and lipids
• familial hypercholestrolemia
• cholestrol and lipids
• statins (3HMG CoA reductase inhibitors)

Question 48

50 year old man gives a 6 month history of generalised weakness and weight loss. He is found to have the following rash.

What is the rash?

List 3 investigations would you perform?

List two treatments?

Answer 48

• dermatitis herpetiformis
  
  • back, elboes, scalp, buttocks, and posterior neck.
• Ix:
  
  • FBC
  • TFT
  • Skin biopsy
  • TTG antibodies or anti-endomysial antibodies
  • plasma glucose
  • serum calcium
  • U&Es and CXR
• Treatments:
  
  • gluten free diet
  • dapasone
• all patients with this condition have coeliacs disease.
  
  • diagnosis confirmed with IgA deposits and direct immunofluorescence.
  • its associated with HLA-B8/DRw3 haplotype:
    
    • T1DM
    • Autoimmune thyroid disease
    • pernicious anaemia