Dermatology
1.
What is the commonest cause for this appearance? (Please select 1 option)
Herpes virus infection Correct Systemic lupus erythematosus Ulcerative colitis
Streptococcal infection Salmonella typhi infection
The slide shows typical target lesions of erythema multiforme (EM). Herpes simplex virus infection is the commonest cause. Other common causes include infection with mycoplasma and streptococci; EM may also be idiopathic, drug-induced (sulfonamides, sulphonylurea, barbiturates), or occur in systemic diseases (SLE, inflammatory bowel disease, malignancy).
2. A 48 year-old diabetic man presents with a 24 hour history of an increasingly painful left leg.
What is the most likely causative organism? (Please select 1 option)
Group A Streptococcus
Group B Streptococcus Correct Group G Streptococcus
Staphylococcus aureus Staphylococcus epidermidis
Ascending cellulitis is shown. Staphylococcus aureus & Streptococci are the commonest causative organisms. Group B Streptoccus has a prediliction for diabetic patients and is the likliest causative organism in this scenario.
3. This 16-year-old boy has a long history of recurrent infections since childhood. What is the most likely diagnosis?
(Please select 1 option) Abetalipoproteinaemia
Chediak-Higashi syndrome Correct Chronic granulomatous disease Kearn Sayre syndrome
Type 1 Diabetes Mellitus The picture shows an albino fundus.
Albinism represents a group of inherited abnormalities of melanin synthesis characterized by a congenital reduction or absence of melanin pigment in association with specific developmental changes in the optic system resulting from the hypopigmentation.
Oculocutaneous albinism (OCA) involves two regions of the body: the skin and hair and the optic system including the eye and the optic nerves. Ocular albinism (OA) has the same changes in the optic system by reducing mainly the pigment in the retinal pigment epithelium of the eye usually with no clinical difference in the color of the skin and hair. The albino macula is always hypoplastic and the patient has reduced acuity and pendular nystagmus. Strabismus is also common.
Tyrosinase-related oculocutaneous albinism (OCA1)An autosomal recessive disorder characterized by absence of pigment in hair, skin, and eyes, and does not vary with race or age. Severe nystagmus, photophobia, and reduced visual acuity are common features. OCA1 is divided into 2 types: type IA, characterized by complete lack of tyrosinase activity due to production of an inactive enzyme, and type IB (also called Yellow OCA), characterized by reduced activity of tyrosinase.
P-gene related oculocutaneous albinism (OCA2)OCA2 is the most common type of albinism, and is especially frequent among African Americans and Africans. The
estimated frequency of OCA2 in the African American population is 1 in 10,000, which contrasts with a frequency of 1 in 36,000 in Caucasians.
Chediak-Higashi SyndromeAutosomal recessive. Patients may have a silvery sheen to their skin, and blue to brown irises. Patients have an increased susceptibility to infection, hepatosplenomegaly, lymphadenopathy and a predisposition to development of a
lymphoma-like condition.
Hermansky-Pudlak SyndromeAutosomal recessive. Associated with the absence of platelet dense-bodies, resulting in a loss of secondary aggregation of platelets after stimulation and a predisposition to bruising and bleeding which can be severe. There is a higher frequency in Puerto Rico.
Ocular albinism
X-linked ocular albinism type 1 (OA1)Although this type of albinism is categorized as a type of ocular albinism, the melanocytes in the skin and hair follicles are also involved. Individuals with OA1 have normal looking cutaneous pigment, variable iris pigment and reduced or absent retinal pigment associated with foveal hypoplasia and optic tract misrouting. The OA1 gene maps to the X chromosome at Xp22.3.
Of the other options listed in the question:
Abetalipoproteinaemia is associated with retinitis pigmentosa. Chronic granulomatous disease presents with recurrent infections due to an inability to generate the oxidative burst necessary for phagocyte killing; it is not associated with any fundal abnormality. Cystic fibrosis is associated with recurrent lower respiratory tract infections but not with fundal abnormality. Type 1 DM is associated with infections and eye disease - though diabetic retinopathy does not have this appearance
4. A 46-year-old man presents with an extensive pruritic rash shown in picture A. 2 weeks previously he had a sore throat with the appearence shown in picture B.
What is the cause of the rash? (Please select 1 option)
Cutaneous T-cell lymphoma Guttate psoriasis Correct Pituriasis Rosea
Pityriasis Rubra Pilaris Scarlet fever
Guttate psoriasis takes its name from the appearence of the lesions which are 'drop like'. It is a common presentation of psoriasis in children and young adults and may often follow and upper respiratory tract infection especially Streptococcal.
Pityriasis Rosea is of unknown aetiology and is a widespread pink patchy rash that appears after a 'herald patch'.
Pityriasis Rubra Pilaris is a papulosquamous disorder of unknown aetiology which presents as red-orange plaques. It is a cause of erythroderma.
Amyloidosis Sarcoidosis
Secondary syphilis Squamous cell carcinoma Tuberculosis Correct
The slide shows cutaneous tuberculosis (lupus vulgaris). Cutaneous TB usually occurs due to spread from an endogenous source; >80% of cases occur on the face and neck. Lesions begin as papules and coalesce to form a plaque. The centre of the lesion consists of scar tissue while the lesion extends from the periphery; apple-jelly nodules are
classically described at the margins of the lesions. 6.
What is the diagnosis? (Please select 1 option)
Erythema annulare Erythema nodosum
Erythema multiforme Correct Erythema marginatum
Erythema migrans
The slide shows typical target lesions of erythema multiforme. "EM, first described in 1860 by von Hebra, is characterized by symmetrical target-like lesions. These lesions are described as erythematous papules surrounded by a raised, erythematous ring, which is in turn encircled by an erythematous outer ring. The lesions are generally located on the extremities
7. Which of the following therapies is the most appropriate for inducing remission of this condition?
(Please select 1 option) Systemic corticosteroids Venesection Correct Gluten-free diet
Aciclovir
Porphyria cutanea tarda (PCT) is associated with deficiency of hepatic uroporphyrinogen (URO) decarboxylase. Cutaneous photosensitivity is the predominant clinical finding. Excess alcohol, iron and oestrogen are common precipitants. The condition may be familial. Treatment is with withdrawal of the precipitant. Venesection is effetive (450ml/week) until haemoglobin is 12g/dl.Chloroquine may also be effective as it promotes porphyrin excretion.
8. This patient presented with a three month history of a gradually enlarging rash on her foot. She had a past history of rheumatoid arthritis. Urine dipstick was negative and a fasting blood glucose was normal.
What is the most likely diagnosis? (Please select 1 option)
Squamous cell carcinoma Myxoedema
Neuropathic ulcer Morphoea
Necrobiosis may prescede symptoms and signs of diabetes by several months.
9. Which of the following statements are correct regarding this patient's condition?
(Please select 1 option)
It occurs more commonly in men
Rheumatoid factor is positive in >90% of cases It is associated with an erosive arthritis
Raynaud's phenomenon is a feature in ~10%
It is associated with a reduced transfer factor Correct
The slide shows a patient with systemic sclerosis (SSc). Features present include
microstomia, facial telangiectasia and beaking of the nose. Rheumatoid factor is positive in 25% of cases; positive ANF in 95%. Autoantibodies strongly associated with SSc include antinucleolar antibodies and anti-U3 nucleolar RNP. Anticentromere antibodies are strongly associated with CREST syndrome. The CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia) is a
localised form of SSc generally associated with a better prognosis. The distinction between CREST and SSc cannot be made on the basis of a picture alone.
10. A 31-year-old man was referred to the dermatology clinic after developing a rash on his arms and legs, predominantly on the knees and elbows. The rash had been present for four weeks.
He had a history of hypertension and had been started on treatment with furosemide and rampiril by his General Practitioner six months previously. He also had a long history of bipolar disorder and had been started on lithium three months previously by his
psychiatrist having been taking chlorpromazine for five years. Six weeks previously he had been given a course of oxytetracycline for acne.
Which of his medications is most likely to have precipitated the rash? (Please select 1 option)
Chlorpromazine Furosemide Lithium Correct Oxytetracycline Ramipril
The clinical history gives a good description of psoriasis. Lithium is the most likely precipitant. Several drugs are known to exacerbate or trigger the onset of psoriasis, including:
1. Beta blockers 2. Lithium 3. Antimalarials 4. NSAIDs
Reactions may occur form less than one month to one year after the medication is initiated. Treatment of drug-induced psoriasis comprises withdrawal of all beta-blocking medications, nonsteroidal anti-inflammatory drugs, antimalarials and lithium, unless absolutely necessary. Skin punch biopsy may be performed to exclude other forms of erythroderma or pustulosis. Bed rest, bland topical compresses, and low potency topical steroids are useful. Frequent emollient use is advisable. Etretinate, methotrexate, or phototherapy might be considered.
11. This 19-year-old woman presented to the Accident & Emergency department complaining of painful legs.
What is the most likely cause for these lesions? (Please select 1 option)
Secondary syphilis Cat scratch fever Oral contraceptive pill Sarcoidosis
Streptococcal infection Correct
Erythema nodosum is characterised by the presence of tender subcutaneous nodules, usually on the shins. Histology of these lesions shows a vasculitis of small venules and panniculitis. The commonest cause is Streptococcal infection. Other common common causes include: other upper respiratory tract infections; sarcoidosis, inflammatory bowel disease. Less common causes: TB, histoplasmosis, coccidioidomycosis, psittacosis, cat scratch fever, Yersinia infection, Salmonellosis, Chlamydial infection, drugs (oral contraceptive, sulfonamides, aspartame, bromides, iodides)
12. An 18 year-old young girl presented with a pruritic rash This rash had started as a single lesion on her abdomen two weeks previously with multiple smaller lesions developing over the chest and abdomen. She was known to have asthma and hay fever, and was taking salbutamol inhalers. There was a family history of diabetes. A urine examination was negative for glucose.
Examination revealed a scaly rash over the abdomen and chest wall (see slide). What is the most likely diagnosis?
(Please select 1 option) Eczema
Erythema multiforme Erythema migrans Guttate psoriasis
Pityriasis rosea Correct
This is the classical history of pityriasis rosea. There is a history of a herald patch, which presents as a single large erythematous plaque on the trunk. This is followed by multiple erythematous plaques along the rib lines on the chest and abdomen, within a few weeks of the herald patch. The condition is self limiting, can be pruritic or asymptomatic and usually lasts 6-8 weeks. The aetiology is unknown. No particular treatment is necessary, although moisturizers can help the pruritus. Pustular psoriasis is as the name suggests characterized by crops of pustules. There are some misleading information with regards
to the history of atopy and family history of diabetes. Classical eczema affects the flexures. This is misleading information to make you think of eczema, which is not what the picture shows.
13. A 35-year-old man was seen in the Accident and Emergency department with a two-week history of earache. The pain in his ear had not settled despite a 10-day course of amoxicillin from his General Practitioner. He subsequently became more unwell with dyspnoea at rest.
On examination he was febrile (38.5°C). Pulse 130 bpm, regular; BP 100/60 mmHg. A widespread macular rash was noted. His ECG showed a sinus tachycardia with
widespread T-wave inversion. Transthoracic echocardiogram did not show any valvular abnormality; left ventricular ejection fraction was reduced.
What is the most likely causative organism? (Please select 1 option)
Haemophilus influenzae
Mycoplasma pneumoniae Correct Staphylococcus aureus
Streptococcus pneumoniae Viridans streptococci
The patient has recognised complications of mycoplasma infection: the history and findings are suggestive of myocarditis; erythema multiforme is shown on the slide. The preceding history of earache may have been bullous myringitis
14. A 47 year-old lady presented two weeks after returning from a holiday in the Caribbean complaining of an intensely pruritic rash on her abdomen.
What is the causative organsim? (Please select 1 option)
Ancylostoma braziliense Correct
Chironex fleckeri Southcott (Box Jelly Fish) Borrelia burgdorferi
Onchocerca volvulus Treponema pallidum
The figure shows cutaneous larva migrans (creeping eruption). Usually caused by an animal hookworm, most commonly Ancylostoma braziliense. The infection is acquired by direct contact with dog or cat faeces – often acquired when sunbathing on
contaminated sand, etc. The larvae burrow in the dermo-epidermal junction. Symptoms include pruritis and a raised, serpiginous erythematous rash that migrates at a rate of up to 1 cm/day. Treatment is with topical thiobendazole, or oral albendazole. Acute infection with the human nematodes Strongyloides stercoralis, Necator americanus and
Ancylostoma duodenale, may produce a similar appearance.
15. A 78-year-old, mentally subnormal, gentleman is admitted to hospital with an acute exacerbation of congestive cardiac failure. He is currently on bumetanide 2mgs TDS, carvedilol 25mgs daily, perindopril 4mgs BD and was recently started on spironolactone 100mgs dly.
On examination you notice severe raised plaques of psoriasis covering his chest, elbows, knees and scalp. He mentions that he has been treating it with topical creams for years but has seen no improvement and did not search for any further advice because of embarrassment.
What treatment do you recommend for his psoriasis? (Please select 1 option)
Start methotrexate Advise tar applications Refer for PUVA Correct
Start on oral steroids and taper off gradually
The safest treatment – that which produces the best clinical effect with minimal side effects in this patient – would be PUVA. Oral Steroids are contraindicated in psoriasis and although one may see an initial improvement, a very serious rebound effect may be seen.
16. A 73-year-old lady presents with fatigue. Investigations show:
Haemoglobin 8.5 g/dL (11.5-16.5) MCV 69 fL (80-96)
White cell count 5.2 x109/L (4-11 x109) Platelets 240 x109/L (150-400 x109)
Physical examination reveals several erythematous lesions on the tongue:
She was transfused with 4 units of packed red cells. Oesophago-gastro duodenoscopy and colonoscopy did not demonstrate any other lesions within the gastrointestinal tract.
What is the best course of subsequent management? (Please select 1 option)
Argon beam ablation therapy Genetic counselling
Nasal skin graft Mefenamic acid
Oral iron therapy Correct
The slide shows the typical appearance of Hereditary Haemorrhagic Telangiectasia - an autosomal dominant condition associated with bleeding (usually nose and GI tract) from early teens and worsening after the age of 50. There may also be AV malformations of the brain, lung and GI tract.
Argon ablation is used for Gastric antral vascular ectasia (GAVE) (Gastroenterology 1984;87:1165-70). Nasal skin grafts are used for persistent epistaxis but this lady has telangiectasia in many other places. Oestrogen therapy can be effective especially in women but the evidence is not strong.
17. This 35 year-old lady was referred to the outpatient clinic for advice regarding persistent acne. Glycosuria was noted on urine dipstick testing.
What is the most likely diagnosis? (Please select 1 option)
Addison's disease
Polycystic ovarian syndrome Correct Congenital adrenal hyperplasia
Acromegaly Ovarian cancer
The slide shows axillary acanthosis nigricans. The history implies that the patient has polycystic ovarian syndrome - a known association of acanthosis nigricans.
Which of the following is the most important in establishing the cause of these lesions? (Please select 1 option)
Anti-streptolysin O titre Skin biopsy
Chest X-ray Correct
Erythrocyte sedimentation rate
Serum angiotensin converting enzyme (ACE)
Erythema nodosum is shown in the slide. The commonest precipitant is a streptococcal infection. However, the commonest potentially serious causes (an therefore those that should be excluded first) include sarcoidosis and tuberculosis. A chest X-ray is an important investigation to exclude both of these causes.
19. What is the diagnosis? (Please select 1 option)
Addison's disease Leukoplakia
Lichen planus Correct Oral candidiasis
Systemic sclerosis
The slide shows lichen planus on the oral mucosa. Skin lesions are usually raised, flat-topped and violaceous with a fine white lace-like surface pattern (Wickham's striae). Oral lesions are common. (Further Reading - Cochrane Review)
Differentiating other white lesions in the oral mucosa.
Hairy leukoplakia - Lateral tongue borders, hairy projections, human immunodeficiency virus or other immunosuppression
Lichen Planus - White lacy lines on buccal mucosa, with associated cutaneous rash Leukoplakia - Evidence or suspicion of intraoral trauma or premalignant lesion
20. This lesion developed over the course of 6 weeks in a 58-year-old male patient. Basal cell carcinoma
Keratoacanthoma Correct Malignant Melanoma Molluscum contagiosum Kaposi’s sarcoma
Keratoacanthoma (KA) is a relatively common low-grade malignancy that originates in the pilosebaceous glands and resembles squamous cell carcinoma (SCC) pathologically. They are believed to develop from the hair follicle, and are said to be more common in males. Some experts support classifying KA as a variant of invasive SCC. KA is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases. Lesions typically are solitary and begin as firm, roundish, skin-colored or reddish papules that rapidly progress to dome-shaped nodules with a smooth shiny surface and a central crateriform ulceration or keratin plug that may project like a horn.
21. A 29-year-old woman was referred to the medical intake by her General Practitioner because of the appearance of a rash on her legs. Ten days previously she had seen her GP complaining of a sore throat and had been given a seven-day course of amoxicillin.
On examination she appeared well. She was febrile (38oC), pulse 90 beats per minute in sinus rhythm with blood pressure 135/80 mmHg. Palpable purpura were seen on her buttocks and the back of both thighs, extending down to the ankles.
Urinalysis showed protein (+) and blood (+). What is the most likely cause of the purpura? (Please select 1 option)
Allergy to amoxicillin Epstein Barr virus infection
Group A Streptococcus infection Correct Infective endocarditis
Meningococcal septicaemia
The description of the rash and its distribution is highly suggestive of Henoch-Schonlein purpura (HSP). The presence of protein and blood onurine dipstick testing suggests co-existing nephritis. The most likely precipitant is a Group A Streptococcal infection that caused the sore throat ten days earlier.
The main initial concern would be to exclude meningococcal septicaemia. The patient has had this illness for several days and does not appear to be critically ill. Overwhelming infection with DIC is therefore unlikely.
There are insufficient features to be able to diagnose infective endocarditis. EBV infection is associated with a rash if ampicillin is administered; the rash with this phenomenon is typically maculopapular and not vasculitic.
Allergic reactions to penicillins usually manifest as a maculopapular rash and not vasculitis. Allergy does not explain the haematuria and proteinuria.
22. This 82 year-old Jewish lady presented with this rash. Immunofluorescent staining of a skin biopsy from this patient showed intercellular deposition of IgG within the
What is the diagnosis? (Please select 1 option)
Staphylococcal scalded skin syndrome Necrolytic migratory erythema
Pemphigoid
Dermatitis herpetiformis Pemphigus vulgaris Correct
The slide shows the characteristic rash of pemphigus vulgaris. Blisters are thin-walled and rupture easily (intact blisters are rarely seen). Large surface area of the body can be affected and the mortality without treatment is high. Mucosal involvement is common at presentation (unlike pemphigoid). Treatment is with high-dose corticosteroids.
Pemphigus vulgaris is a blistering disease seen predominantly in elderly patients. It is characterised by the formation of thin-walled blisters that rupture easily.
Immunofluorescent staining of a biopsy sample shows deposition of IgG directed against intercellular cement - resulting in a 'chicken wire' appearance.
Pemphigoid rarely involves the mucosa and presents with large tense intact blisters. Immunofluorescence shows deposition of IgG and complement at the dermo-epidermal junction.
23. This 60 year-old man presented to his General Practitioner with a three-month history of proximal muscle weakness. He was a smoker of 20 cigarettes a day for 40 years.
From the following list, which would be the TWO most appropriate investigations to perform in order to establish the diagnosis?
(Please select 2 options)
ACTH stimulation (synachthen) test Blood glucose level
Electromyography Correct Serum albumin
Serum anti-Scl-70 antibody Serum creatine kinase Correct Serum iron & ferritin saturation
Twenty four hour urinary cortisol excretion Uncuffed serum calcium
Urinary porphyrins
The slide shows dermatomyositis. In older patients presenting for the first time with dermatomyositis an underlying malignancy should be considered. Malignancies most commonly associated with dermatomyositis include lung, ovary, breast and G-I. The diagnosis is usually made by demonstrating elevated CK with an abnormal EMG (showing spontaneous fibrillation). Treatment is with glucocorticoids, which is often associated with remission of symptoms, even with an underlying malignancy.
24. This 40-year-old female is admitted with a 2 month history of abdominal pains, watery diarrhoea and has noted this extensive rash.
What is this rash? (Please select 1 option)
Acquired ichthyosis Erythema ab igne
Erythema repens gyratum Erythema migrans
Necrolytic migratory erythema Correct
The symptoms with this rash which is typical of Necrolytic Migratory Erythema suggests a glucagonoma. Other features of glucagonoma include diabetes mellitus,
hypoaminoacidemia, cheilosis, normochromic normocytic anemia, venous thrombosis and neuropsychiatric features. At least 50% are metastatic at presentation so prognosis is poor. Acquired ichthyosis appears as symmetrical scaling of the skin and is a cutaneous manifestation of underlying malignancy. Erythema migrans is associated with Lyme disease. Erythema ab igne/livedo reticularis has the appearance of chain mail. Erythema repens gyratum is another paraneoplastic phenomenon commonly lung, breast, stomach etc.
25. This 60 year-old man presented to his General Practitioner with a three-month history of proximal muscle weakness. He was a smoker of 20 cigarettes a day for 40 years.
What is the diagnosis? (Please select 1 option)
Dermatomyositis Correct Polymyalgia rheumatica Cushing's syndrome Myotonic dystrophy
Ectopic parathyroid hormone production
Dermatomyositis is an autoimmune disease characterized by polymyositis and a skin rash. The classic purple (heliotrope) rash is seen on sun-exposed areas, especially the eyelids, nose, cheeks, forehead, knees, knuckles and around the nail beds. The rash may be pruritic. In older patients presenting for the first time with dermatomyositis an underlying malignancy should be considered. Malignancies most commonly associated with dermatomyositis include lung, ovary, breast and G-I.
26. A 45-year-old gardener was referred to the Dermatology clinic with a
well-circumscribed, raised erythematous lesion on his finger. The lesion had enlarged steadily over the previous three weeks, was tender and bled easily when touched.
What is the most likely diagnosis? (Please select 1 option)
Cutaneous anthrax Keratoacanthoma Malignant melanoma
Mycobacterium marinum infection Pyogenic granuloma Correct
Pyogenic granuloma (lobular capillary haemangioma) is benign vascular lesion of the skin and mucosa. The cause is unknown. The name is a double misnomer--the lesion is neither pyogenic nor a granuloma. Pyogenic granulomata are usually solitary lesions, appearing as a glistening red papule or nodule that is prone to bleeding and ulceration. Lesions often grow rapidly (over weeks), frequently occurring at sites of trauma and commonly involve the digits, arms, head and face. Pathologically, it is an inflammatory lesion composed of granulation tissue and chronic inflammatory cells.
Keratoacanthoma is a low-grade malignancy that originates in the pilosebaceous glands. Clinically and pathologically the lesions resemble squamous cell carcinoma. Lesions typically are solitary with a central area of ulceration that may contain a characteristic keratin plug.
Cutaneous anthrax would not be expected on the basis of the history given. Anthrax lesions begin as reddened, indurated papules, later becoming necrotic with a
characteristic black centre (eschar). Pictures of cutaneous anthrax appear in the MRCP Part 2 exam, though the usual history given is of someone from (or who has visited) the Middle East and had contact with cattle/sheep/goats.
Malignant melanomas may occur at any site, but given the context provided in this case, is a less likely option.
Mycobacterium marinum is the cause of Fish Tank Granuloma. Lesions are ovoid and usually occur on the hands (following contact with fish). Fishermen, fishmongers and tropical fish enthusiasts are susceptible.
*Sporotrichosis (caused by Sporothrix schenckii) is usually acquired by contamination of wounds with soil - characteristically a rose thorn. Although these patients can present with skin lesions, they are usually multiple and associated with regional adenopathy and systemic symptoms/sepsis. This was felt to be too specialised for inclusion in a MRCP Part 2 question, but candidates should consider this diagnostic possibility in this epidemiological context (a gardener) but should take the clinical presentation & any images into account also.
A 40-year-old male presents with this lesion on his leg which has been present for approximately three months and is minimally painful. He has also been aware of recurrent bouts of abdominal pain and bloody diarrhoea.
What is the most likely diagnosis? (Please select 1 option)
Acute intermittent porphyria Collagenous colitis
Crohn's disease Glucagonoma
Ulcerative colitis Correct
This picture shows pyoderma gangrenosum which occurs in 2% patients with UC (less common in Crohns). It is most common on the lower limb and in scars or sites of previous trauma. It is treated by immunosupression. Dermatitis herpetiformis is
associated with Coeliac disease and is characteristically very itchy. Neuro-psychological episodes are associated with AIP and Migratory necrolytic erythema is associated with Glucagonoma.
What is the diagnosis? (Please select 1 option)
Erythema ab igne Erythema nodosum
Necrobiosis Lipoidica Diabeticorum Post-phlebitic leg
Pre-tibial myxoedema Correct
This is pretibial myxoedema with the raised, indurated pinkish patches. Can occur anywhere but typically on the shins and dorsum of feet. Often found with acropachy and ophthalmopathy and a high titre of TSH recpetor antibodies would be expected.
What is the diagnosis in this 78 year-old man? (Please select 1 option)
Pemphigus vulgaris Dermatitis herpetiformis Toxic epidermal necrolysis Necrolytic migratory erythema Pemphigoid Correct
Pemphigoid is a disease of the elderly (>60 years) characterised by the development of large blisters that heal without scarring. The condition is caused by IgG autoantibodies against components of the basement membrane. Blistering in pemphigoid occurs at the subepidermal level – deeper than the blisters of pemphigus vulgaris (which occur at the dermal-epidermal junction). Hence the tense blisters seen in pemphigoid; blisters are thin-walled and fragile in pemphigus – few intact blisters are ever seen.
What is the diagnsosis? (Please select 1 option) Tuberculoid leprosy Pyoderma gangrenosum Morphoea
Necrobiosis lipoidica dibeticorum Correct Pre-tibial myxoedema
Necrobiosis lipoidica is associated with diabetes mellitus. It is commoner in females than males. The lesions are painless.
31. This 28 year-old man presented to hospital after becoming progressively more breathless over the preceeding day. He had developed a dry cough and reported
expectoration of bright red blood. He gave a history of malaise and low-grade fever for 5 days. The rash (pictured) had appeared three days before presentation.
(Please select 1 option)
Intravenous benzyl penicillin + flucloxacillin pyrazinamide + ethambutol High-dose corticosteroids
Co-amoxiclav + clarithromycin
Rifampicin + isoniazid + pyrazinamide + ethambutol Intravenous aciclovir Correct
The slide shows the typical rash of chickenpox. Varicella pneumonia occurs in up to 20% of adults with chickenpox, appearing 3-5 days into the course of the illness. Symptoms include tachypnoea, cough, dyspnoea, and fever. Cyanosis, pleuritic chest pain and haemoptysis are common. In adults with pneumonitis, treatment with aciclovir is warranted.
32. A 61-year-old diabetic patient shows you this skin eruption which has developed over the course of 4 weeks on the dorsum of his foot.
(Please select 1 option) Biopsy
Dapsone
Observation Correct
Surgical excision with a 2cm excision margin Surgical excision with a 5cm excision margin
This is granuloma annulare, the site may well be atypical in diabetic patients. The treatment is "masterful inactivity". The eruption should disappear spontaneously. It is characterised by a raised annular configuration. No common sequaelae are recognised, although rarely it may involve underlying fascia or tendon sheaths. Some evidence exists of aberrant cellular-mediated immune response in adults, but these studies have not been replicated in children. No treatment has been shown to categorically alter the course of the lesion. The most obvious differential would be necrobiosis lipoidica diabeticorum. Amelanocytic malignant melanoma is a theoretical possibility,
33. This patient with advanced HIV disease noted the appearance of these lesions on her face over several weeks
What is the causative agent? (Please select 1 option)
Bartonella hensalae Cryptococcus neoformans
Human herpesvirus 8 Human papilloma virus Pox virus Correct
Molluscum contagiosum is a disease caused by a poxvirus of the Molluscipox virus genus that produces a benign self-limited papular eruption of multiple umbilicated cutaneous tumors. This common viral disease is confined to the skin and mucous membranes. Transmission requires direct contact with infected hosts or contaminated fomites. It is generally thought to infect humans exclusively, but there are a few isolated reports of Molluscum contagiosum occurring in chickens, sparrows, pigeons,
chimpanzees, kangaroos, a dog, and a horse. The infection is found worldwide and has a higher incidence in children, sexually active adults, and those who are immunodeficent.
This disease is transmitted primarily through direct skin contact with an infected
individual. Fomites have been suggested as another source of infection, with molluscum contagiosum reportedly acquired from bath towels, tattoo instruments, and in beauty parlors and Turkish baths. The average incubation time is between 2 and 7 weeks with a range extending out to 6 months.
The slide shows the typical papules (with central umbilcation) associated with molluscum contagiosum. Molluscum contagiosum is sometimes presented in MRCP Part 2 in
association with a tattoo.
Bartonella hensalae is the bacterium that causes cat-scratch disease. Cryptococcus neoformans can cause cutaneous lesions in advanced HIV disease, but the appearance here is not typical of cryptococcosis.
34. A 22-year-old lady presented to Casualty Department having had a grand mal seizure whilst in the shopping centre. She had not complained of feeling unwell prior to the event. She had a past medical of learning difficulties and had been referred to a
dermatologist in the last year with lesions over her face. Otherwise she took no regular medication, did not smoke or drink alcohol.
On examination she was post-ictal. Her vital signs were stable. She had pink nodules with a smooth glistening surface affecting the cheeks and nasolabial folds. In addition, there were elevated flesh-coloured lesions over the trunk. Fundoscopy revealed bilateral retinal phakomas, but the rest of the cranial nerves were intact. Peripheral nervous system examination did not reveal any obvious abnormalities apart from bilaterally brisk reflexes with bilateral extensor plantar responses.
Investigations revealed:
Haemoglobin 14.6 g/dL (13.0-18.0 g/dL) Mean cell volume 92 fL (80-96 fL)
White cell count 6.1 x109/L ( 4-11 x109/L) Platelets 239 x 109/L (150-400 x109/L) Serum sodium 139 mmol/L (137-144 mmol/L) Serum potassium 4.6 mmol/L (3.5-4.9 mmol/L)
Serum urea 4.8 mmol/L (2.5-7.5 mmol/L) Serum creatinine 95 µmol/L (60-110)
Serum calcium 2.4 mmol/L (2.2-2.6 mmol/L) Serum C-reactive protein <5 U/L (<5 U/L)
Serum albumin 39 g/L (37-49 g/L) Fasting plasma glucose 5.6 mmol/L (3-6 mmol/L)
A CT scan of the brain was performed. A pre-contrast image from this study is shown below:
What is the most likely diagnosis? (Please select 1 option)
Gardner's syndrome
Multiple endocrine neoplasia type Ib Neurofibromatosis
Tuberose sclerosis Correct Von Hippel-Lindau Syndrome
This patient has Tuberose Sclerosis. Fibromas may also develop within the CNS, where they calcify typically in the periventricular area. Other manifestations of tuberose sclerosis include Ash-leaf macules, which are discrete areas of hypopigmentation, often present at birth, shagreen patch in the form of a rough patch of skin with a texture similar to shark skin and adenoma sebaceum, which is angiofibromas of the face. (For further reading see Tuberous Sclerosis Association Guidelines)
35. This patient originally presented ten years ago with a pruritic rash on her abdomen. These lesions now cover her entire body.
This disease is caused by infiltration of: (Please select 1 option)
B-cells
T-cells Correct Neutrophils Mast cells Eosinophils
The diagnosis is mycosis fungoides, a cutaneous T-cell lymphoma. The disease presents as a pruritic eczematous rash – the pre-malignant stage, and develops telangiectasiae and areas of 'cigarette paper' atrophy (poikiloderma atrophicans vasculare). As malignancy develops, nodular lesions appear and progress to become necrotic.
36. his 45 year-old white female presented to her General Practitioner asking for advice regarding removal of these lesions for cosmetic reasons.
What additional investigation should be performed? (Please select 1 option)
Biopsy of lesion for histology Serum Cryptococcal antigen assay HIV antibody test Correct Tzanck smear
Herpes virus serology
Umbilicated, pearly papules 2-5mm in diameter. Seen in patients with advanced HIV/AIDS (CD4 count <200 cells/mm3). Caused by a pox virus. Commonly occur on face, especially near the eyelids; also occur on genitals and trunk. Treated with
cryotherapy, liquid nitrogen or curettage.
What is the likely diagnosis? (Please select 1 option)
Erysipelas Correct Impetigo
Lupus pernio Lupus Vulgaris Rosacea
Erysipelas is a streptococcal pyogenes infection of the deep dermis and subcutis. Treatment relies upon IV antibiotics such as Benzylpenicillin and Erythromycin. Complications include sepsis, cerebral abscess and venous sinus thrombosis.
38. An elderly man presents with an ulcer over his lower leg. He had previously served in the navy and had spent a lot of time in Thailand. There was a history of high alcohol
intake and was a heavy smoker for many years. He had a past history of Rheumatoid arthritis, but was lost to follow up 10 years previously. He developed this ulcer 4 weeks previously and despite treatment with oral erythromycin for presumed infective causes continued to increase in size.
Investigations revealed:
Haemoglobin 12.4 g/dL (13.0-18.0) White cell count 12 x109/L (4-11 x109)
Platelet count 344 x109/L (150-400 x109) MCV 104 fL (80-96)
Liver function tests Normal
Chest X-ray No abnormality detected What is the most likely diagnosis?
(Please select 1 option) Cutaneous tuberculosis
Pyoderma gangrenosum Correct Squamous cell carcinoma
Yaws
Pyoderma gangrenosum typically is an expanding ulcer with a polycyclic or serpigenous outline and a characteristic undermined bluish edge. It can be associated with
inflammatory bowel disease, rheumatoid arthritis, monoclonal gammopathies and leukemia. It usually responds to oral steroids. The pathogenesis is unknown, and is presumed to be immunological. Both yaws and syphilis can cause ulcers but typically affect the palms and the soles of the feet. Squamous cell carcinomas usually are
hyperkeratotic tumours although they can ulcerate. The dorsum of the foot is an unusual site. Cutaneous TB can present as ulceration but there is usually a more chronic course. This question has many clues away from the diagnosis for an ulcer of infective etiology, but pyoderma gangrenosum is the most likely ulcer.
39. A 47-year-old Turkish man presented to casualty with this lesion on his arm. He also complained of discomfort in the left axilla. The lesion had developed over a period of two weeks and was painless. There was no past history of note. He had recently returned from a vacation to his parents’ goat farm in Turkey.
What is the diagnosis? (Please select 1 option)
Orf
Cutaneous anthrax Correct Pyoderma gangrenosum Brucellosis
Plague
The slide shows the typical appearance of cutaneous anthrax, caused by Bacillus anthracis. Cutaneous disease is the commonest form of the infection in humans and is usually due to contact with infected animals or animal products. Anthrax is endemic to herd animals in some parts of the world. Following exposure, the skin lesion evolves over a period of ~2 weeks into a papule, pustule, vesicle and eventually forms an ulcer with a central black eschar. The surrounding skin is usually boggy and oedematous. Lesions are usually painless with tender regional lymph nodes. Lesions heal spontaneously in 80-90% of cases; 10-20% of patients progress and become bacteraemic – associated with a high mortality. Penicillin is effective in treating the infection.
40. This 34-year-old female presents with a one month history of weight loss, fatigue and this painless rash on her shin.
Which of the following investigations would you choose for this patient? (Please select 1 option)
ACE concentrations
Anti-TSH receptor antibodies Correct Chest X-ray
Fasting plasma glucose OGD with duodenal biopsy
This is pre-tibial myxoedema with slightly raised, pinkish, indurated patches usually on the fronts of the shins or dorsum of the foot and often associated with acropachy. A high titre of TSH receptor antibody is invariably associated with the dermopathy.
41. This 70-year-old patient presents with weight gain and lethargy. Her legs have the appearances depicted in the clinical picture. Which of the following tests is most appropriate?
(Please select 1 option) cold agglutinins cryoglobulins fasting glucose
serum immunoglobulins Thyroid function tests Correct
This patient has erythema ab igne. It classically presents on the front of the legs due to the patient sitting too close to a fire or heater. It may also arise as a response to chronic hot water bottle use. Patients with hypothyroidism experience fatigue, put on weight and have cold intolerance, often resorting to spending long periods in front of an electric heater or fire. This may result in the changes described above, and thus the most important test is TFTs.
42. What is the diagnosis? (Please select 1 option)
Dermatomyositis Correct Erysipelas
Lupus pernio Myasthenia gravis
Systemic lupus erythematosus
The characteristic cutaneous features of DM are heliotrope rash and Gottron’s papules. Several other cutaneous features, including malar erythema, and poikiloderma (ie,
variegated telangiectasia, hyperpigmentation) in a photosensitive distribution, violaceous erythema on the extensor surfaces, and periungual and cuticular changes, are
characteristic of the disease even though they are not pathognomonic.
The characteristic heliotrope rash consists of a violaceous or erythematous rash
(sometimes with oedema) in a symmetrical distribution involving periorbital skin. This is frequently subtle and may involve only a mild discoloration along the eyelid margin. Since a heliotrope rash is rarely observed in other disorders, its presence is highly suggestive of DM.
Gottron’s papules are found over bony prominences, particularly the
metacarpophalangeal joints, the proximal interphalangeal joints, and/or the distal interphalangeal joints. Papules may also be found overlying the elbows, knees, and/or feet. The lesions consist of slightly elevated violaceous papules and plaques and may be scaly. Nailfold changes consist of periungual telangiectases and/or a characteristic cuticular change with hypertrophy of the cuticle and small hemorrhagic infarcts with this hypertrophic area.
43. With which of the following is this condition associated? Bronchiectasis Correct
Carcinoma of the bronchus Gout
Trichophyton rubrum infection Tuberose sclerosis
Yellow nail syndrome is caused by hypoplastic lymphatics and is characterised by the triad of lymphoedema, pleural effusions and yellow discolouration of the nails. Approximately 40% of patients also have bronchiectasis.
44. A 42-year-old man presented to the Dermatology outpatient clinic with a pruritic photosensitive skin rash. His liver function tests were abnormal. Histology from his liver biopsy is shown.
What is the diagnosis? (Please select 1 option)
Dermatomyositis Mastocytosis
Molluscum contagiosum Pemphigus vulgaris
Porphyria cutanea tarda Correct
Porphyria cutanea tarda (PCT) is associated with reduced hepatic uroporphyrinogen decarboxylase activity and risk factors such as alcohol abuse, medication (e.g. oral contraceptives and certain other drugs) and hepatitis C virus (HCV) infection. When exposed to light, uroporphyrinogen generates free radicals that cause blistering of the skin. PCT can be treated with phlebotomy to deplete the excess iron stores that exacerbate the porphyria.
A 56-year-old seaman presents to his general practitioner with this appearance on the front of his legs. He has had this lesion for at least one year and has received treatment with topical steroids and courses of antibiotics. Despite this the lesion has deteriorated. The lesion is painless and recently he has noticed that the centre has broken down and is slightly oozing. He has a 5 year history of diabetes mellitus and receives metformin 500 mg tds. He has also undergone dermatological surgery for skin malignancies on his face over the last six years.
What is this skin lesion? (Please select 1 option)
Arteriopathic ulcer Basal cell carcinoma
Necrobiosis lipoidica diabeticorum Correct Squamous cell carcinoma
Yaws
This patient has type 2 diabetes mellitus and this long-standing skin rash. Necrobiosis is often mistaken for eczema but rather than responding to steroids may actually deteriorate. Occasionally ulceration of the lesion may occur. Necrobiosis is typically painless. The lesion does not have the appearances of a squamous cell carcinoma which would have an irregular raised edge and more necrotic. This is not the site for an arteriopathic ulcer which is usually found on the foot.
46. This 52-year-old female presents with a one day history of fever and this facial appearance. The patient is penicillin allergic having had a problems with facial swelling previously.
Which of the following antibiotics would be the most appropriate treatment for this patient?
(Please select 1 option) Cefuroxime Chloramphenicol Co-trimoxazole
Erythromycin Correct Vancomycin
Erysipelas is a Streptococcus pyogenes infection of the deep dermis and subcutis. Treatment relies upon IV antibiotics such as Benzylpenicillin and Erythromycin. In a penicillin allergic patient clearly a macrolide is the drug of choice from the above list. There is a 10% cross allergy between cephalosporins and penicillins. Although the organism is likely to be sensitive to both vancomycin and chloramphenicol, the latter is used with limitations due to the incidence of aplastic anaemia and the former tends to
have restricted use due to nephrotoxicity. Complications include sepsis, cerebral abscess and venous sinus thrombosis.
47. A 26-year-old male epileptic is admitted with temperature and rash. Over the last one week a rash has developed and he has become iller. Recently he has had some problems with epileptic control and has commenced carbamazepine with valproate.
Examination reveals an unwell patient with a temperature of 39oC, a diffuse
erythematous, painful rash with evidence of some lateral sliding of these erythematous areas on palpation. There is also blistering and inflammation of the oral cavity.
What is the likely diagnosis? (Please select 1 option)
Exfoliative dermatitis
Erythema elevatum diutinum Pustular psoriasis
Toxic epidermal necrolysis Correct Toxic shock syndrome
This patient's presentation and clinical description suggests a diagnosis of Toxic Epidermal Necrolysis (TEN) due to Carbazepine therapy. TEN is a severe
mucocutaneous exfoliative disease with an uncertain pathogenesis and a high mortality rate. It is difficult to say whether it is another variant of Stevens-Johnson Syndrome and treatment of both are similar. It is often idiopathic but may be associated with viral infections, leukaemia, lymphoma and drugs - in particular Sulphonamides and
anticonvulsants. The suggested association with carbamezipine in this case makes toxic shock syndrome due to Staphylococcus aureus remote which like Pustular psoriasis would not be expected to affect the mucous membranes.
48. A 45 year-old dockyard worker presented with symptoms of fatigue and general malaise. He also reported developing ulcers on his hands after minor trauma.
What is the most likely diagnosis? (Please select 1 option)
Acute intermittent porphyria Alcoholic haemosiderosis Contact dermatitis
Haemachromatosis
Porphyria cutanea tarda Correct
Porphyria cutanea tarda (PCT) is associated with deficiency of hepatic uroporphyrinogen (URO) decarboxylase. The major clinical feature is cutaneous photosensitivity. Bullae
develop on sun-exposed areas and lesions heal slowly, leaving scars. Porphyrins are increased in liver, plasma, urine and stool. Porphobilinigen (PBG) is normal. Factors contributing to PCT are alcohol (the commonest cause), excess iron and excess oestrogens.
49. A 44-year-old HIV seropositive man presented to the clinic with this rash.
What agent should be used to treat this condition? (Please select 1 option)
Aciclovir Correct Flucloxacillin Ganciclovir Malathion
Topical corticosteroids
50. his 35 year-old patient presented with a four month history of nausea and weight loss (8 kg). He complained of vague abdominal discomfort with no clear exacerbating or relieving factors. His only past history was of a partial gastrectomy twenty years previously for a gastric ulcer. He was not taking any prescribed medications.
What is the most likely diagnosis? (Please select 1 option)
Adenocarcinoma of the stomach Correct Carcinoma of the pancreas
Blind loop syndrome Peptic ulcer disease
Acute intermittent porphyria
Acanthosis nigricans (pictured) has a characteristic hyperpigmented, velvety surface. It frequently occurs in the axillae, groins and in the skin fold of the neck and occasionally on the dorsum of the hand. Acanthosis nigricans is associated with: endocrine disease (acromegaly, Cushing's syndrome, insulin resistant diabetes mellitus), in polycystic ovary syndrome and as a paraneoplastic phenomenon (usually tumours of the GI tract,
especially adenocarcinoma of the stomach)
What is the diagnosis? (Please select 1 option)
Erythema multiforme Correct Erythema marginatum
Erythema nodosum Erythema gyratum repens Erythema ab igne
The slide shows typical target lesions of erythema multiforme.
Which of the following autoantibodies is highly specific for this condition? (Please select 1 option)
Rheumatoid factor Anticardiolipin antibody Antinuclear factor
Anticentromere antibody Correct Antimitochondrial antibody
The slide shows the hands of a patient with systemic sclerosis/CREST (the distinction cannot be made on the basis of the picture alone). Rheumatoid factor is non-specific and is positive in 25% of cases; ANF is positive 95%. Autoantibodies strongly associated with SSc include antinucleolar antibodies and anti-U3 nucleolar RNP. Anticentromere
antibodies are strongly associated with CREST syndrome. Anti-SSA (Ro) and anti-SSB (La) antibodies are seen in SSc associated with Sjogren’s syndrome. Anticardiolipin antibodies may be found in association with SLE. Antimitochondrial antibodies are associated with primary biliary cholangitis. Anti-RNP antibodies are also associated with mixed connective tissue disease.
(Please select 1 option) Chickenpox
Herpes simplex infection
Molluscum contagiosum Correct Herpes zoster
Simple warts
Molluscum contagiosum is a disease caused by a poxvirus of the Molluscipox virus genus that produces a benign self-limited papular eruption of multiple umbilicated cutaneous tumors. This common viral disease is confined to the skin and mucous membranes. Transmission requires direct contact with infected hosts or contaminated fomites. It is generally thought to infect humans exclusively, but there are a few isolated reports of Molluscum contagiosum occurring in chickens, sparrows, pigeons,
chimpanzees, kangaroos, a dog, and a horse. The infection is found worldwide and has a higher incidence in children, sexually active adults, and those who are immunodeficent. This disease is transmitted primarily through direct skin contact with an infected
individual. Fomites have been suggested as another source of infection, with molluscum contagiosum reportedly acquired from bath towels, tattoo instruments, and in beauty parlors and Turkish baths. The average incubation time is between 2 and 7 weeks with a range extending out to 6 months.
The slide shows the typical papules (with central umbilcation) associated with molluscum contagiosum. Molluscum contagiosum is sometimes presented in MRCP Part 2 in
association with a tattoo.
54. This gentleman first presented in his early 20's with haemoptysis. He has required intermittent blood transfusions throughout his life.
What is the diagnosis? (Please select 1 option)
Hereditary haemorrhagic telangiectasia Correct Wegener's granulomatosis
Kaposi's sarcoma Hepatitis C
Peutz-Jegher's syndrome
Typical telangiectasia of hereditary haemorrhagic telangiectasia (also known as Osler-Weber-Rendu syndrome) are seen. The condition is inherited as an autosomal dominant trait; sporadic cases also occur. Patients typically present early in adult life with anaemia due to occult bleeding from gastrointestinal telangiectasiae. Lesions commonly occur in the mouth and on the face. Complications of the disease include haemoptysis and pulmonary haemorrhage.
55. This 52 year-old Greek woman presented with a right popliteal deep vein thrombosis. What is the most likely diagnosis?
(Please select 1 option) Reitter's syndrome Crohn's disease Secondary syphilis Pemphigus vulgaris Behcet's disease Correct
Behcet's disease is a rare multisystem vasculitis commoner in males than females. Clinical features include the classical triad of (1) recurrent oral ulceration (2) recurrent genital ulceration (3) iritis. Other features include fever, abdominal pain, diarrhoea, episcleritis, polyarteritis, arterial and venous thromboses, and pericarditis. Patients may exhibit pathergy (developnment of pustules at venepuncture sites). HLA B5 is associated with ocular disease; HLA B12 is associated with recurrent oral ulcers. Treatment is with steroids or colchicine.
56. A young woman presents to clinic with a 3 week history of intermittent joint pain and raised rash over lower legs (picture). She complained of pain on palpation of the rash on the lower legs. There was no history of recent travel and no other recent illnesses. She had a previous history of type 1diabetes, for which she receives basal bolus insulin therapy. She had a family history of diabetes on her maternal side and psoriasis on her paternal side.
What investigation should be performed next? (Please select 1 option)
Chest X-ray Correct Complement levels Rheumatoid factor Skin Biopsy
X-Ray wrists and ankles
The picture shows erythema nodosum. This is inflammation of the subcutaneous tissue (panniculitis) and is tender and palpable. It has a number of causes. The most important causes to exclude are TB and sarcoidosis. It is therefore important to perform a CXR. Other causes include infections (such as streptococcus infections), drugs (sulphonamides, OCP), inflammatory bowel disease and Bechets. Apart from the CXR, a throat culture, ASOT, Mantoux test, and biochemistry are important. Lesions tend to last 6-8 weeks. Apart from treating the underlying cause, Non steroidal anti-inflammatory drugs and bed rest are helpful. The history of diabetes and family history of psoriasis are coincidental.
57. This 71 year-old lady presented with several months' history of facial discomfort and a perceived change in her facial expression. She also complained of having 'gritty' eyes. What is the diagnosis?
(Please select 1 option) Sarcoidosis
Systemic sclerosis Correct Relapsing polychondritis Wegener's granulomatosis Systemic lupus erythematosis
The photograph shows typical features of systemic sclerosis, including facial
telangiectasia, small mouth, beaking of the nose. The diagnosis could also have been CREST syndrome since neither Raynaud's, oesophageal dysmotility or calcinosis can be seen in this picture.
58. This 60-year-old lady presented with sweats, facial pain and general malaise for three days. Examination revealed the appearances as shown below. Her temperature was 38.8oC, pulse of 102 beats per minute and blood pressure of 122/78 mmHg.
What is the diagnosis?
(Please select 1 option) Erysipelas Correct Infective endocarditis Lupus pernio
Systemic Lupus erythematosis Thyrotoxicosis
This patient has erysipelas which is a facial cellulitis caused by Strep Pyogenes species. Sepsis, cerebral venous thrombosis or abscess may complicate this condition. The organism is usually responsive to penicillins.
59. This 40-year-old male presents with a cough, weight loss and these lesions on his foot. He has no past medical history, denies drug use, and drinks 25 units of alcohol per week. He has never married, and travels the world in his capacity as the CEO of a successful computer company. What is the likely diagnosis?
(Please select 1 option) Basal cell carcinoma Kapsoi’s sarcoma Correct Malignant Melanoma Non-Hodgkin’s lymphoma Squamous cell carcinoma
This is the typical lesion of Kaposi’s sarcoma. It is induced by human herpes virus 8 infection in patients with HIV. This patient may have contracted HIV on his travels and a full sexual history would be indicated, followed by appropriate counselling and an HIV test. Karposi’s is on the decline due to the advent of highly active antiretroviral therapy.
60. A 22-year-old male student presents with generalised pruritus of six weeks duration. He has little other history of note and has otherwise been well. This itching has
deteriorated over this time and is particularly worse at night. He has little other history of note, has been unaware of any rashes and denies taking any precribed drugs. There is no history of atopy. He shares a flat with his girlfriend and drinks approximately 12 units per week and smokes cannabis occassionally.
On examination, there is little of note except there are some scratch marks over the shoulders and back and he has some erythema between the fingers. Otherwise cardiovascular, respiratory and abdominal examination is normal.
Which of the following therapies would be most appropriate treatment for this patient? (Please select 1 option)
Astemizole Calamine lotion Chlorpromazine Ciprofloxacin
This patient has scabies, a highly contagious disease caused by the mite, Sarcoptes Scabiei and is quite common in the sexually active. It is well recognised to cause
generalised pruritus and one should make a careful examination betwen the finger spaces for burrows. Appropriate treatment includes Permethrin cream topical Benzyl Benzoate or malathion.
61. A 50-year-old wine grower presented with a 6-month history of recurrent blisters on the dorsum of his hand. These tended to be worse in the summer and were occasionally itchy. He had previously lived in the tropics when he was in the army. His only
medication was bendroflumethiazide for hypertension and had been on the same treatment for the previous 3 years. A picture of the hands is shown.
What is the diagnosis? (Please select 1 option)
Drug reaction Eczema
Porphyria cutanea tarda Correct Scabies
Out of the possible answers porphyria cutanea tarda is the most likely to induce a blistering rash on the dorsum of the hand. It is usually seen in men who have damaged their liver by drinking too much alcohol. This patient was a vintner who may suggest regular alcohol intake the blisters formed on the face and backs of the hands, in response to sunlight or minor trauma. These areas can become scarred and hairy. The urine is pink and fluoresces coral pink under wood’s light. Treatment is by avoidance of alcohol and oestrogens and venesection. The pruritic nature of the lesions should not make you think of scabies, as the classical hallmark of scabies are burrows. Bendrofluozide can induce photosensitivity but the history of no new treatment is against this being a drug reaction. Pompholyx eczema can cause vesicles mainly on the palmar aspect of the hands.
62. This 28 year-old man presented to hospital after becoming progressively more breathless over the preceeding day. He had developed a dry cough and reported
expectoration of bright red blood. He gave a history of malaise and low-grade fever for 5 days. The rash (pictured) had appeared three days before presentation.
What is the most likely diagnosis? (Please select 1 option)
Varicella pneumonia Correct Goodpasture's syndrome Meningiococcal septicaemia Wegener's granulomatosis Tuberculosis
The slide shows the typical rash of chickenpox. Varicella pneumonia occurs in up to 20% of adults with chickenpox, appearing 3-5 days into the course of the illness. Symptoms include tachypnoea, cough, dyspnoea, and fever. Cyanosis, pleuritic chest pain and haemoptysis are common. CXR shows patchy shadowing. About 30 young adults die each year from varicella pneumonia and they are best managed on a High-Dependency Unit.
