INT.MEDICINE Batch 2014- College of Medicine EVALS # 1 TOPICS: ANATOMY AND PHYSIOLOGY OF THE SKIN – DR. DAYRIT DERMATOLOGIC INFECTIONS AND INFESTATIONS – DR. ESCUADRO ECZEMA, PSORIASIS AND EXFOLIATIVE DERMATITIS – DR. TOLEDO CUTANEOUS MANIFESTATIONS OF SYSTEMIC DISEASE – DR. CRISOSTOMO HEALTHCARE-ASSOCIATED INFECTIONS – DR. ABU BY: RJ Paras and Kristine Espinoza 1. Squamous cell carcinoma of the skin is a malignant proliferation of a. Melanocytes b. Langerhans cells c. Keratinocytes d. Lymphocytes Three basic cell types of the epidermis: Keratinocytes 1. squamous cell 2. ectodermal origin 3. production of keratin a. surface coat of the epidermis b. structural protein of hair & nails 4. Key Implications: Atopic dermatitis, Squamous cell carcinoma (C. Answer) ii. Melanocytes (A.) 1. neural crest origin 2. nucleus smaller & more deeply basophilic than basal keratinocyte , dendritic cytoplasm 3. 1 melanocyte:4 basal keratinocytes (cheeks) to 1:10 (limbs) → forming with them an ”epidermal melanin unit” 4. production of melanin 5. Key Implications: Vitiligo, Melanoma, Hyperpigmentation iii. Langerhans cells (B.) 1. clear, dendritic cells just above the middle of the spinous zone of the epidermis 2. striking cytoplasmic vacuolation 3. electron microscopy: lobulated nucleus and Birbeck granules (rod/racquet inclusions 4. potent stimulators of T-cell mediated immunoreactions 5. Key Implications: Inflammatory skin diseases iv. Lymphocytes (D.) i. 2. The ratio of the epidermal-melanin unit (melanocyte:basal cells) on the limbs is: a. 1:2 b. 1:4 c. 1:10 d. 1:20 From the Answer to Question 1, digest. 1 melanocyte : 4 basal keratinocytes (in the cheeks), whereas 1:10 (in the limbs) → which forme with them an ”epidermal melanin unit.” (C.) 3. Clonal proliferation of Langerhans cells which is rare and usually presents in infancy as a widespread eruption of erythematous macules and papules, fever and organomegaly a. Mastocytosis b. Juvenile xanthogranuloma c. Histiocytosis x d. Eruptive xanthoma External source: Clonal proliferation of Langerhans cells, abnormal cells deriving from bone marrow and capable of migrating from skin to lymph nodes. Clinically, its manifestations range from isolated bone lesions to multisystem disease. Langerhans cells Histiocytosis is part of a group of clinical syndromes called histiocytoses, which are characterized by an abnormal proliferation of histiocytes (an archaic term for activated dendritic cells and macrophages). These diseases are related to other forms of abnormal proliferation of white blood cells, such as leukemias and lymphomas. Commonly seen are a rash which varies from scaly erythematous lesions to red papules pronounced in intertriginous areas. Internal Medicine Ratio - 2014 Page 1 Up to 80% of LCH patients have extensive eruptions on the scalp. 4. A. B. C. D. A connective tissue disease which demonstrates sclerosis and hyalinization of collagen, and appears clinically as tense, hardened skin: a. Lupus profundus b. Scleroderma c. Dermatomyositis d. Juvenile Rheumatoid arthritis Lupus erythematosus (Profundus – ) 1. Acute cutaneous lupus erythematosus Classic butterfly rash or malar rash of SLE Localized ACLE – confluent symmetric erythema and edema are centered over the malar eminences and bridges over the nose; nasolabial folds are characteristically spared Generalized ACLE – widespread morbilliform or exanthematous eruption often focused over the extensor aspects of the arms and hands and characteristically sparing the knuckles Precipitated or exacerbated by exposure to UV light Scleroderma (Systemic Sclerosis) Typical presenting features are esophageal reflux and dysmotility and swelling or skin textural changes in the extremities First presentation is typically arthralgia, stiffness and swelling of the extremities. Later, the features of skin sclerosis develop Dermatomyositis In 60% of patients, cutaneous lesions and muscle weakness present simultaneously. Onset of cutaneous disease is typically accompanied by pruritus and/or a burning skin sensation Gottron sign and Gottron papules are pathognomonic Periorbital, confluent, macular, violaceous (heliotrope) erythema/edema and grossly visible periungual telangiectasia are highly characteristic Rheumatoid arthritis 1. Rheumatoid nodule subcutaneous nodule that occurs in approximately ¼ of patients with RA more than 90% of patients have seropositive RA usual location is over pressure points such as the olecranon, the extensor surface of the forearms and achilles tendon 2. Bywaters lesions Digital pulp papules associated with nail fold telangiectasias and minute digital ulcerations or petechiae Manifestations of mild vasculitis 5. Clonal proliferation of medium sized to large lymphocytes with convoluted nuclei and have tendency for epidermotropism. Clinically appears as erythematous patches and plaques with hypo- and hyper- (mottled pigmentation) and atrophy on sun-protected areas: a. Langerhans cell histiocytosis b. Plasmacytoma c. Mastocytosis d. Cutaneous T-cell lymphoma / Mycosis fungoides External source: Most common form of cutaneous T-cell lymphoma. It generally affects the skin, but may progress internally over time. Symptoms include rash, tumors, skin lesions, and itchy skin. While the cause remains unclear, most cases are not genetic or hereditary. Most cases are in people over 20 years of age, and it is more common in men than women. Treatment options include sunlight exposure, ultraviolet light, topical steroids, chemotherapy, and radiation. 6. Major cell involved in granulomatous diseases such as Cutaneous Tuberculosis and Leprosy in which one of its major functions is phagocytosis a. Neutrophils b. Eosinophils c. Histiocytes d. Mast cells Fact. Digest. 7. a. b. c. A form of alopecia where there is total loss of scalp and body hair a. Alopecia universalis b. Alopecia totalis c. Alopecia mucinosa d. Ophiasis Alopecia universalis - total loss of body hair (includes scalp) Alopecia totalis - complete scalp baldness Alopecia mucinosa - erythematous plaques or flat patches without hair primarily on the scalp and face Internal Medicine Ratio - 2014 Page 2 d. Ophiasis - form of alopecia characterized by the loss of hair in the shape of a wave at the circumference of the head 8. An infectious disease which presents with varied skin lesions and abnormal sensation and is characterized histiogically by perineural infiltration by histiocytes and lymphocytes a. Leishmaniasis b. Tuberculosis verrucosa cutis c. Leprosy d. Impetigo External source: Leprosy is characterized by noncaseating granulomas, destruction of dermal nerves, loss of sweat glands and hair follicles, and absent bacilli. Leprosy demonstrates a normal epidermis, subepidermal granulomas particularly around blood vessels, nerves, and skin appendages, foamy histiocytes, and many intracellular acid-fast bacilli. The histologic slide of LL leprosy shows large numbers of acid-fast bacilli (in clusters) in histiocytes and within nerves. 9. Pitting of the nail is usually secondary to abnormal keratinisation of the nail matrix and is normally observed in a. Iron deficiency anemia b. Psoriasis c. Emphysema d. Cutaneous T-cell lymphoma Iron deficiency presents with angular stomatitis, smooth painful tongue, and fragile/brittle nails, which have longitudinal ridging and lamellation. Marked iron deficiency koilonychia develops. Hair changes include diffuse scalp alopecia with brittle, split hairs 10. Usual duration of chronic urticaria a. >2 weeks b. >4weeks c. <6weeks d. >6weeks Acute urticaria: less than 6 weeks Chronic urticaria: beyond 6 weeks 11. The following are cutaneous manifestations in patients with gastrointestinal malignancy, EXCEPT a. Acanthosis nigricans b. Hypertrichosis lanuginose c. Terry’s nails d. Adult-onset dermatomyositis Gastrointestinal Malignancy Adult-onset dermatomyositis is associated with underlying malignant disease. (C.) Pancreatic, gastric and colorectal cancers are the third most common after bronchogenic and ovarian cancers In two-thirds of patients with acanthosis nigricans and cancer, the tumor is gastric, usually adenocarcinoma of the stomach or bowel. (A.) Hypertrichosis lanuginosa is a rare complication of gastrointestinal cancer. (B.) Skin manifestations of hepatobilary disease Jaundice – increased cellular or connective tissue binding of bilirubin and its metabolits in the skin Cholestatic pruritus – although retained cutaneous bile acids have been implicated, there is a poor correlation between the plasma bilirubin and the severity of pruritus Nail changes – intensely white nails (Terry’s nails), splinter haemorrhages, flat or spoon nails (C.) Palmar erythema (“liver palms”) 12. Which of the following is seen in patients with chronic liver disease a. Ichthyosis-like scaling of the skin b. Loss of forearm, axillary and pubic hair c. Pale skin color d. Photosensitivity Chronic Liver Disease Hormone-induced changes of the skin include loss of forearm, axillary and pubic hair in both sexes. Telangiectatic changes, mainly on light-exposed skin (“dollar paper markings”). They fade on pressure with a glass slide and rarely pulsate. (B.) In addition to jaundice, a diffuse muddy gray color in patients is due to basal cell melanin. 13. The following are cutaneous manifestations in patients with chronic liver disease EXCEPT a. Striae distensae b. Dollar paper markings c. Spider nevus d. Eruptive xanthomas Internal Medicine Ratio - 2014 Page 3 Chronic Liver Disease Hormone-induced changes of the skin include loss of forearm, axillary and pubic hair in both sexes. Men experience decreased rate of growth of facial hair, pectoral alopecia, and female pubic hair distribution, as well as loss of libido, testicular atrophy and oligospermia. Stria distensae in both men and women. Telangiectatic changes, mainly on light-exposed skin (“dollar paper markings”). They fade on pressure with a glass slide and rarely pulsate. (B.) In addition to jaundice, a diffuse muddy gray color in patients is due to basal cell melanin. Spider nevus or spider angioma is the most representative and classic vascular lesion. Most common on the face, neck, and upper part of the chest (i.e., over the region drained by the superior vena cava) (C.) Corkscrew sclera vessels (tortuous small arteries that traverse the margins of the ocular sclera) *Eruptive xanthomas are related to diabetic skin disease, later discussed in this rationale. 14. Which of the following is TRUE of primary biliary cirrhosis a. Melanosis involves intertriginous areas b. Pathogenesis of melanosis is due to the presence of excess melanin with no stainable iron c. Lightening of freckles and areola d. Diffuse linear pigmentation on the palms Primary biliary cirrhosis Melanosis is common and may be an early presenting sign. It initially involves exposed areas, but it gradually becomes generalized. (A.) Pathogenesis: presence of excess melanin with no stainable iron (B.) Accentuation of normal freckling and areolar pigmentation (C.) Localized linear pigmentation may appear in the creases of the fingers and palms. (D.) Blotchy, circumscribed areas of dirty brown pigmentation Pigmentation resembling chloasma Guttate hypomelanosis appear on the buttocks, back, thighs and forearms Dermal, subcutaneous and tendon xanthomas are common and can be extensive 15. The following are cutaneous manifestations in patients with chronic renal failure EXCEPT a. Uremic frost b. Renal pruritus c. Subepidermal bullae d. Metastatic calcification of the skin Chronic renal failure Skin of patients are typically dry, often with ichthyosis-like scaling – due in part from altered vitamin A metabolism along with the fluid volume shifts of dialysis Skin color is pale from anemia and often exhibits a distinctive gray-yellow hue due to accumulation of carotenoid and nitrogenous pigments (urochromes) in the dermis. Renal pruritus – incidence is as high as 90% of patients undergoing hemodialysis. (B.) Is thought to be caused by a combination of increased serum histamine, vitamin A and parathyroid hormone; mast cell hyperplasia; peripheral polyneuropathy; and xerosis Porphyria cutanea tarda has been described in patients with CRF undergoing hemodialysis - may be due to inadequate clearance of plasma-bound porphyria precursors by urine excretion or hemodialysis; presents as photosensitivity and subepidermal bullae (C.) Metastatic calcification of the skin results from secondary or tertiary hyperparathyroidism. Abnormally elevated levels of PTH may trigger deposition of crystalline calcium pyrophosphate in the dermis, subcutatneous fat or arterial walls. (D.) More Information Occasionally, calcified vessels may thrombose acutely, resulting in calciphylaxis Acquired perforating dermatosis can occur in association with CRF and diabetes mellitus – occurs in up to 10% of patients undergoing hemodialysis Nephrogenic fibrosing dermopathy – resembles scleromyxedema, presenting with progressively developing erythematous, sclerotic dermal plaques on the arms and legs, with sparing of the head and neck; pruritus is common. 16. Acanthosis nigricans associated with diabetes mellitus a. Presents as brown to gray-black cutaneous thickening in the extensor areas b. Has a symmetric distribution c. Inguinal area is most severely affected d. No improvement with weight loss Acanthosis nigricans Presents as brown to gray-black papillomatous cutaneous thickening in the flexural areas, including the posterolateral neck, axillae, groin and abdominal folds (A.) Distribution is symmetric (B.) Internal Medicine Ratio - 2014 Page 4 Affected skin has a dirty, velvety texture The back of the neck is the most consistently and severely affected area (C.) When the palms are involved, the rugated appearance of the palmar surface has been called tripe palms Treatment is generally ineffective and may include calcipotriol, salicylic acid, urea, systemic and topical retinoids. Improvement or resolution does occur with weight loss in some obese patients. (D.) 17. Scleroderma diabeticorum a. Painful indurations and thickening of the skin on the upper back and neck b. Has a symmetric distribution c. Treatment is usually successful d. Found in patients with early diabetes Scleroderma Diabeticorum Painless, symmetric induration and thickening of the skin on the upper back and neck, spreading to the face, shoulders and anterior torso (A.) Skin retains a nonpitting, woody, peau d’orange quality Affects 2.5-14% of patients with diabetes and is a disease of long-standing diabetes associated with obesity (D.) Treatment is usually successful, including radiotherapy, low-dose methotrexate, bath psoralen and ultraviolet A light (PUVA), extracorporeal photophoresis, factor XIII, and prostaglandin E1. (C.) (B.) was referring to Question 16. 18. True of eruptive xanthomas in patients with diabetes mellitus EXCEPT a. Often with underlying severe hypertriglyceridemia b. Generally asymptomatic c. Lesions occur in crops and may coalesce into plaques d. Treatment is ineffective Eruptive xanthomas Often with underlying severe hypertriglyceridemia (>1000mg/dl) (A.) 1-4mm reddish-yellow papules on the buttocks and extensor surfaces of the extremities; generally asymptomatic (B.) Lesions occur in crops and may coalesce into plaques over time (C.) Responds rapidly to treatment of hypertriglyceridemia and control of underlying diabetes and usually resolve completely in 6-8 weeks. (D.) 19. Which cutaneous manifestation improves rapidly with control of underlying diabetes mellitus a. Acanthosis nigricans b. Scleroderma diabeticorum c. Eruptive xanthomas d. Necrobiosis lipoidica A. B. C. D. Acanthosis nigricans - Treatment is generally ineffective and may include calcipotriol, salicylic acid, urea, systemic and topical retinoids. Improvement or resolution does occur with weight loss in some obese patients. (A.) Scleroderma diabeticorum - Treatment is usually successful, including radiotherapy, low-dose methotrexate, bath psoralen and ultraviolet A light (PUVA), extracorporeal photophoresis, factor XIII, and prostaglandin E1. (C.) Eruptive xanthomas - Responds rapidly to treatment of hypertriglyceridemia and control of underlying diabetes and usually resolve completely in 6-8 weeks. Necrobiosis lipoidica - Treatment include topical, intralesional or systemic steroids, topical retinoids and topical PUVA Other Skin Diseases Associated with Diabetes Mellitus Diabetic ulcers Callus formation precedes necrosis and breakdown of tissue overy bony prominences of feet, usually on great toe and sole, over first and/or second metacarpophalangeal joints Ulcers are surrounded by a ring of callus and may extend to underlying joint and bone Standard therapy for neuropathic diabetic ulcers includes debridement, off-loading (often non-weight bearing), moist wound care, and protective dressings. Necrobiosis lipoidica Presents with one to several sharply demarcated yellow-brown plaques on the anterior pretibial region. The lesions have a violaceous, irregular border that may be raised and indurated Initially, NL often presents as red-brown papules and nodules. Over time, the lesions flatten, and a central yellow or orange area becomes atrophic and commonly telangiectasias are visible, taking on the characteristic “glazedporcelain” sheen. Aside from the shins, other sites include ankles, calves, thighs, and feet. Although pain and pruritus have been reported, most lesions are asymptomatic. Anesthesia of the plaques does occur. Treatment include topical, intralesional or systemic steroids, topical retinoids and topical PUVA. (D.) Diabetic dermopathy Small (<1cm) atrophic, pink to brown scar-like macules on the pretibial areas. Lesions are asymptomatic and clear within 1-2 years with slight residual atrophy or hypopigmentation Internal Medicine Ratio - 2014 Page 5 No treatment necessary. 20. Found in patients with hypothyroidism a. Dollar paper markings b. Tripe palms c. Myxedema d. Bywaters lesions a. b. c. d. Dollar paper markings – indication of Chronic Liver Disease Tripe palms – indication of Acanthosis Nigricans Myxedema Bywaters lesions - indication of Rheumatoid Arthritis Hypothyroidism Decreased core temperature and increased peripheral vasoconstriction cause the skin to be cool and pale; xerotic Myxedema is the most classic finding. It occurs as a result of dermal accumulation of mucopolysaccharides, namely hyaluronic acid and chondroitin sulphate, and tends to resolve with treatment of the hypothyroidism. Characteristic facial changes include a broadened nose, thickened lips, puffy eyelids, and macroglossia with a smooth and clumsy tongue Skin can be doughy, swollen and waxy but without pitting Hair is coarse, dry and brittle with slowed growth. There can be a loss of eyebrow hair involving the outer third. Nails grow slowly and can be thickened and brittle with longitudinal and transverse striations. 21. A 26 year old male presents to your clinic complaining of a rashes on his back of 4 weeks duration. He describes small, whitish lesions that are not painful and do not itch on his macules that coalesce on his upper back. When the lesions are scratched, fine scales are produced. How should you proceed in the management of this patient? a. A fungal culture from the lesion should be obtained b. A skin biopsy should be performed c. The lesions should be scraped and a KOH stain should be performed d. The patient should be started on oral Terbinafine Suspect: Pityriasis/Tinea Versicolor • Etiology: Malassezia furfur or Pityrosporum orbiculare – Short thick fungal hyphae &spores (“spaghetti & meatballs”) • Clinical Manifestation – Yellowish or brownish macules in pale skin or hypopigmented macules in dark skin – Coalesce to form patches – Delicate scaling (“grattinage”) – Mild itching & minimal inflammation – Sites of Predilection: Sternal region & sides of chest, abdomen, back, pubis, neck, intertriginous areas • Diagnosis • Wood’s Lamp: yellowish or brownish fluorescence • Skin Scraping with 10% KOH: spaghetti & meatballs 22. A 56 year old female with poorly controlled diabetes mellitus developed dry, erythematous scaling patches over her axillary area. Similar lesions are seen in her inguinal area. You bring the patient to a darkened room and use Wood’s lamp. If the lesions fluoresce, what color is diagnostic of erythrasma? a. Coral yellow b. Coral green c. Coral red d. Coral orange From: Rook’s Textbook of Dermatology Wood's lamp is additionally useful in diagnosing erythrasma. The ultraviolet light of a Wood's lamp causes the organism to fluoresce a coral red color, differentiating it from fungal infections and other skin conditions. 23. A 6 year old boy comes with his mother to your clinic with scalp lesion. He developed this lesion a few weeks ago. On physical examination, the patient has an area of alopecia on his scalp; associated with the alopecia is a painful inflammatory mass with pus and sinus tracts. A skin specimen treated with potassium hydroxide (KOH) shows the presence of dermatophytes. A Gram stain shows no bacterial organisms. What is the likely diagnosis for this patient, what is the causal organism, and how should his condition be treated? a. Kerion; Microsporum or Trycophyton; oral griseofulvin b. Bacterial abscess; staphylococcus aureus; oral dicloxacillin c. Fungal and bacterial coinfection; Trycophyton and Staphylococcus aureus; oral itraconazole and dicloxacillin d. Sebaceous tumor; surgical removal Tinea capitis (Ringworm of scalp & Kerion) • Clinical Manifestations • 1. Non Inflammatory Types - Black-dot, Gray patch • 2. Inflammatory Type – Kerion, Favus , Tinea Capitis Internal Medicine Ratio - 2014 Page 6 Non-inflammatory Type • A. Black dot- endothrix; infected hairs broken off at or below the surface of the scalp • B. Gray patch- ectothrix; scaly patches with areas of stubs of broken hair • Endothrix: arthrospores are formed inside the hair shaft; no fluorescence (T. tonsurans, T. schoenleinii, T. violaceum) • Ectothrix: hair is surrounded w/ sheath of tiny spores; greenish fluorescence – Microsporum species (T. verrucosum, T. mentagrophytes, T. megnini) Inflammatory Type • Begins as erythematous, scaly, papular eruptions w/ loose & broken off hairs • A. Kerion- localized spot w/ pronounced swelling, creating a boggy & indurated area exuding pus • B. Favus- concave, sulfur-yellow crust forming around loose wiry hairs • Hyphae & air spaces within the hairshaft • Bluish-white fluorescence Treatment • Griseofulvin x 2-4 mos or at least 2 weeks after negative microscopic and culture examinations • Terbinafine 250mg/ Tab x 2 weeks (Trichophyton) and 4 weeks (Microsporum) • Itraconazole 100mg/caps, 2 caps/day x 4-6 weeks • Ketoconazole 200mg/tab x 4-6 weeks • Others: short courses of systemic steroids for inflammatory type; Selenium sulfide Shampoo or Ketoconazole Shampoo left for 5 mins 3x a week 24. A 33 year old male presented with a tender erythematous well demarcated edematous plaques over his left medial leg. He reposts episodes of fever and chills. What is your primary impression? a. Necrotizing fasciitis b. Cellulitis c. Erythrasma d. Erysipelas Erysipelas A.K.A. St. Anthony’s Fire • Etiology: – Group A Beta hemolytic Strep-supfl dermal lymphatics – Strep C or G-occasional – Group B Strep- newborns, abdominal or perineal erysipelas in post partum women • Erysipelas • Predisposing Factors – Break in the skin barrier – Operative wounds – Fissures in the nares, auditory meatus, under the earlobes, on the anus, penis, between or under the toes (little toe) – Accidental scalp wounds – Chronic leg ulcers • Clinical Presentation – Sites: face & legs – Prodrome: malaise, chills, high grade fever, headache, vomiting & joint pains – Lesions: intensely erythematous (scarlet), warm, swollen, brawny, well-demarcated plaque w/ characteristic raised indurated border • +/- vesicles/bullae w/ seropurulent fluid • Spread; peripheral extension • Lesions • On face: ear may become swollen & distorted; +/- delirium • Leukocytosis (PMNLs >/= 20,000/mm3) – Complications: • Septicemia • Deep Cellulitis - In newborns or surgical operations in the elderly • Treatment – Systemic: at least 10 days, rapid improvement in 24-48 hours – Penicillin V , IV Penicillin, Erythromycin – Supportive Measures: cold compresses 25. A 37 year old woman presents with intense perineal itching. On examination, she has both red papules and blue macules on the inner thighs. In addition, there are excoriated, crusted lesions in the same region. Tiny tan swellings are seen at the bases of some of the pubic hair shafts. What is your diagnosis? a. Dermatitis herpetiformis b. Genital herpes virus c. Pediculosis d. Scabies Dermatitis herpetiformis Characteristics: o intensely itchy Internal Medicine Ratio - 2014 Page 7 o o chronic papulovesicular eruptions distributed symmetrically on extensor surfaces (buttocks, back of neck, scalp, elbows, knees, back, hairline, groin, or face) o The blisters vary in size from very small up to 1 cm across. o Extremely itchy Intense itching or burning sensations are sometimes felt before blisters appear in a particular area. External source: First signs and symptoms of dermatitis herpetiformis are intense itching and burning, the first visible signs are the small papules or vesicles that usually look like red bumps or blisters. Sometimes they appear on the face and along the hairline, and, on occasion, on the shoulders, the lower end of the spinal column, and within the mouth The rash rarely occurs on other mucous membranes, excepting the mouth or lips. The symptoms range in severity from mild to serious, but they are likely to disappear if gluten ingestion is avoided and appropriate treatment is administered. Dermatitis herpetiformis symptoms are chronic, and they tend to come and go, mostly in short periods of time. Sometimes, these symptoms may be accompanied by symptoms of coeliac disease, commonly including abdominal pain, bloating or loose stool, and fatigue. 26. A 17 year old boy living at home with his parents presents with an intensely pruritic papulovesicular eruption involving the hands and wrists. Skin scrapings identify eggs and waste products of Sarcoptes scabiei. Which of the following management options is most appropriate? a. Treat the patient and symptomatic household members with Permethrin 5% cream and tell them to wash all clothing and linens with which they have come into contact over the past 2 days. b. Treat the patient and all household members with Permethrin 5% cream, and tell them to wash all clothing and linens with which they have come into contact over the past 2 days. c. Treat the patient and symptomatic household members with Permethrin 5% cream and tell them to wash all clothing and linens with which they have come into contact over the past 10 days. d. Treat the patient and all household members with Permethrin 5% cream and tell them to wash all clothing and linens with which they come into contact over the past 10 days. External Source (CDC): • It is important to remember that the first time a person gets scabies they usually have no symptoms during the first 2 to 6 weeks they are infested; however they can still spread scabies during this time. st • Permethirin 5% cream is the 1 line of treatment in treating Scabies. • Treatment is also recommended for household members and sexual contacts, particularly those who have had prolonged direct skin-to-skin contact with the infected person. Both sexual and close personal contacts who have had direct prolonged skin-to-skin contact with an infected person within the preceding month should be examined and treated. All persons should be treated at the same time to prevent reinfestation. • Bedding, clothing, and towels used by infested persons or their household, sexual, and close contacts during the two to three days before treatment should be decontaminated by washing in hot water and drying in a hot dryer, by dry-cleaning, or by sealing in a plastic bag for at least 72 hours. Scabies mites generally do not survive more than 2 to 3 days away from human skin. 27. A 33 year old man comes to your clinic complaining of weight loss. He has also been experiencing occasional diarrhea. He started to have these symptoms 4 months ago. He says he has been trying to eat more, but he is still losing weight. Physical examination shows bitemporal wasting diffuse cervical lymphadenopathy, and proximal white subungual lesions. These lesion show dermatophytes on potassium hydroxide (KOH) staining. What is the most likely diagnosis for this patient? a. Graves disease b. HIV infection c. Lymphoma d. Inflammatory bowel disease Proximal Subungal Onychomycosis: • Type of Dermatophytoses • Involves the proximal nail fold (PNF) • White spot appears from beneath the PNF which gradually fills the lunula & moving distally • Maybe an indicator of HIV infection 28. A 22 year old male complained of skin-colored verrucous plaque over his left knee. He claimed that the lesion started as a small, skin-colored papule 4 weeks ago. He reported a history of accidentally falling on a cemented floor 6weeks ago. What is your primary diagnosis? a. Tuberculosis Verrucous Cutis b. Verruca Vulgaris c. Hansens disease d. Ecthyma Tuberculosis Verrucous Cutis: • Paucibacillary caused by exogenous re infection (inoculation) in previously sensitized individuals w/ high immunity • Clinical Manifestations: – Small asymptomatic papule or papulopustule w/ puple inflammatory halo Internal Medicine Ratio - 2014 Page 8 – – – Hyperkeratotic Slow growth & peripheral expansion verrucous plaque w/ irregular border; solitary Spontaneous involutionatrophic scar 29. A 32 year old female complained of solitary, slightly erythematous plaque over her left arm. The plaque has a characteristic elevated border and atrophic center. No pruritus is reported. On further examination, the lesion presented with hyposthesia. What is your impression? a. Leprosy, tuberculoid b. Tinea Corporis c. Leprosy, lepromatous d. Chronic mucocutaneous candidiasis Tuberculoid Leprosy • Lesions are solitary, few & asymmetrical • Lesion: large erythematous plaque w/ sharply elevated border & atrophic center • Sensory: anesthetic or hyposthetic & anhidrotic • Nerve involvement: early, superficial peripheral nerves are enlarged, tender or both 30. How will you manage this patient? a. Topical Ketoconazole, applied BID for 2 weeks b. Rifampin 600 mg once a month for 6 months and Dapsone 100mg OD x 6 months c. Rifampin 600mg and Clofazimine 300mg once a month and Dapsone 100 mg and Clofazimine 50mg OD x 12 months d. Oral Fluconazole 150mg once a week WHO Protocol for Hansen’s Disease: • Single lesion Paucibacillary – Single dose: Rifampin 600mg, Ofloxacin 400mg & Minocycline 100mg (ROM) • Paucibacillary [(Indeterminate, Tuberculoid Leporsy (TT)] – Rifampin 600mg once a month x 6 months – Dapsone 100mg OD x 6 months 31. Which statement is NOT true about exfoliative dermatitis? a. It may be caused by a preceding eczematous disease b. It may be caused by preceding systemic disease (SLE) c. It may occur as an idiopathic entity (without a preceding dermatitis or systemic disease) d. None of the above Exfoliative Dermatitis: • a.k.a. Erythroderma • Inflammatory skin disease in which erythema and scaling is widespread/generalized (“GED” = generalized exfoliative dermatitis) • Due to a preceding skin or systemic disease – SKIN Diseases= Eczematous dermatitis, Psoriasis, superficial fungal infections (dermatophytosis), scabies – SYSTEMIC Diseases = Cancers (leukemia, lymphoma, rectal CA, lungCA), HIV infection • Drugs implicated – DRUGS = allopurinol, NSAIDS, anticonvulsants/ psychotropic drugs(Carbamezapine, Phenytoin, Lithium), antibiotics (penicillin, trimethoprim, sulfonamides, sulfonyureas, INH/Rifampicin, etc.) • May occur as an idiopathic entity w/o preceding dermatitis or systemic disease 32. Drugs commonly implicated in Exfoliative dermatitis a. Allopurinol b. NSAIDs c. Anticonvulsants d. A and B only e. A, B, and C Refer to #31 33. This result in previously sensitized skin a. Irritant contact dermatitis b. Allergic contact dermatitis c. Contact dermatitis d. Atopic dermatitis Allergic Contact Dermatitis: • Results when an allergen comes into contact with previously sensitized skin • Results from a specific acquired hypersensitivity of the delayed type – a.k.a. cell-mediated immunity or cellmediated hypersensitivity • May be induced upon a sensitized area of skin when an allergen is taken internally Internal Medicine Ratio - 2014 Page 9 • Patient may have exposure to an allergen for years before developing hypersensitivity e.g. hair dyes, rubber, cosmetics, insecticides 34. Also known as eruptive psoriasis and can be triggered by a prior infection a. Guttate psoriasis b. Inverse psoriasis c. Psoriasis vulgaris d. Pustular psoriasis Guttate Psoriasis (guttate = droplike) • a.k.a.“eruptive” psoriasis (sudden/acute onset) • Trunk and proximal extremities most affected 35. Coin-shaped eczema also known as a. Seborrheic dermatitis b. Nummular dermatitis c. Contact dermatitis d. Stasis dermatitis *From 2010 Tranx Nummular Dermatitis: • Characterized by circular or oval “coin-like” lesions • Begin as small edematous papules that become crusted and scaly • Unknown etiology, but dry skin is a contributing factor • Common locations: trunk or the extensor surfaces of the extremities, particularly on the pretibial areas or dorsum of the hands • Occurs more frequently in men • Most commonly seen in middle age • Treatment is similar to that of atopic dermatitis 36. Which is a major criteria for atopic dermatitis a. Xerosis b. Early age of onset c. Pruritus d. Elevated serum IgE Atopic Dermatitis: • A chronic, relapsing inflammatory skin disease affecting up to 20% of the population • A multigenic disorder = the genetics of atopy are complex • Has a serious impact on the quality of life of patients and their families • Increasing prevalence worldwide noted due to 1. Environmental factors : house dust mites, airborne allergens, poor air quality, poorly-ventilated homes 2. “Western lifestyle” factors: Increased urbanization, increasing industrialization in dev. countries stress, dietary changes, travel to new environments, new microbial environment, most time spent indoors, more pets • Diagnosis is arrived at by history taking and clinical criteria (based on Clinical criteria as guidelines for dx of AD by Rajka and Hanifin): A. Major criteria (3 or more): 1. Pruritus 2. Typical morphology and distribution - Adults: Flexural lichenification - Children: Facial and Extensor involvement 3. Chronic or chronically relapsing dermatitis 4. Personal/Family Hx of ATOPY (asthma, allergic rhinitis aka “hay fever”, atopic dermatitis, allergic conjunctivitis, GI allergy) B. Minor features (3 or more): 1. Xerosis (dry skin) 2. Ichthosis/palmar hyperlinearity/ keratosis pilaris 3. Immediate(type I) skin test reactivity 4. Elevated serum IgE 5. Early age of onset 6. Tendency towards skin infections(esp. S.aureus & Herpes simplex) / impaired cellmediated immunity 7. Tendency towards nonspecific hand or foot dermatitis 8. Nipple eczema 9. Cheilitis 10. Recurrent conjunctivitis 11. Dennie-Morgan infraorbital folds 12. Keratoconus 13. Anterior subcapsular cataracts 14. Orbital darkening Internal Medicine Ratio - 2014 Page 10 15. 16. 17. 18. 19. 20. 21. 22. 23. Facial pallor/erythema Pityriasis alba Anterior neck fold Itch when sweating Intolerance to wool and lipid solvents Perifollicular accentuation Food intolerance Course influenced by environemental and emotional factors White dermographism 37. Which statement is true regarding phototherapy a. It is used for eczematous disease only b. It is only used for psoriasis patients c. It is used for exfoliative dermatitis d. All of the above Eczema Treatment: • Topical Regimen – Steroids – hydrocortisone, dexamethasone, mometasone, methylprednisolone, triamcinolone, betamethasone, clobetasol, fluocinolone – Antibiotics – gram-positive coverage, broad-spectrum – Immunomodulatory drugs – tacrolimus – Emollients / Moisturizers /hypoallergenic cleansers • Systemic Drugs – Antihistamines – sedating/ non-sedating – Antibiotics – Steroids – prednisone, methylprednisolone, hydrocortisone – Immunomodulatory drugs – cyclosporine, methotrexate, azathioprine • Phototherapy – Use of ultraviolet light: 1. UVA-1 atopic dermatitis 2. Narrow-band UVB • Intralesional injections of corticosteroids Psoriasis Treatment: • TOPICAL Treatment = applied to skin – Glucocotricosteroids – Vitamin D3 analogues: calcipotriol – Topical retinoid: Tazarotene – Tar – Anthralin – Emollients/ Moisturizers: eg. Petroleum jelly commonly used because cheap but greasiness is uncomfortable • SYSTEMIC Treatment (oral/IM/ IV) – Methotrexate – Cyclosporine – Retinoids (Vit A derivatives)= etretinate, acitretin – Biologicals : genetically engineered medication from a living organism (e.g. virus), gene or protein injected or infused intravenously = e.g. etanercept , infliximab • PHOTOTHERAPY - Treatment with ultraviolet (UV) light – Photochemotherapy : PUVA = a photosensitizer (methoxypsoralen) is ingested and the patient is subjected to UVA light – UVB light = broad band UVB = narrow band UVB Exfoliative Dermatitis Treatment: • Exfoliative dermatitis commonly resists therapy until the underlying disease is treated (eg. phototherapy, systemic medications in psoriasis).* *External Source 38. Which is NOT true about psoriasis? a. It occurs at any age b. Most cases have a positive family history c. It peaks at age 16-22 years old d. It peaks at 55-60 years old *The answer indicated was A, but according to the ppt, all of them are characteristics of psoriasis, so the answer should be none of the above. Psoriasis: • A chronic, relapsing disease characterized by red, scaling skin lesions of variable forms • Affects about 2% of population • (+) Genetic predisposition • 1/3 of patients have (+)family history Internal Medicine Ratio - 2014 Page 11 • • Occurs at ANY AGE PEAKS at 2 age groups: – 16-22 y/o and 55-60 y/o 39. Which is NOT a distribution pattern of seborrheic dermatitis a. Scalp b. Eyebrows c. Extensor surfaces d. Flexor surfaces *From 2010 Tranx Seborrheic Dermatitis: • Common, chronic disorder characterized by greasy scales overlying erythematous patches or plaques with variable pruritis • Most common location: scalp (recognized as severe dandruff) • “Seborrheic distribution”: Eyebrows, nasolabial folds, eyelids, glabella, post-auricular area, periorbital, upper back, flexural areas • May also be seen in central chest, axilla, groin, submammary folds, and gluteal cleft • Age of onset – 2 peaks – Infancy (within 1st 3 months) – evident in scalp “cradle cap” – yellow, greasy, adherent scales th th – 4 -7 decade • Epidemiology: – Male > Female – 85% patients with AIDS – No racial predilection 40. Which area is NOT commonly affected in psoriasis vulgaris a. Lower back b. Cheeks c. Scalp d. Retroauricular areas Psoriasis Vulgaris: • Circular plaques predominantly on scalp (particularly) retroauricular areas , elbows & knees, lower back (lumbar area) • “Chronic stationary psoriasis” – months/yrs. 41. Standard precautions should be applied to which of the following admitted patients a. A 3month old baby girl with fever and rash b. A 12year old boy who sustained a leg fracture c. A 37year old pregnant mother with vaginal bleeding d. A 60year old diabetic man complaining of severe chest pain e. All of the above Standard Precautions: • Primary strategy for successful prevention and control of healthcare-associated infections • Designed for the care of ALL patients in hospitals, REGARDLESS of their diagnosis or presumed infection status • Goals: 1. Reduce the risk of transmission of bloodborne pathogens 2. Reduce the risk of transmission of pathogens from moist body substances (ie. Blood, all body fluids except sweat, non-intact skin, mucous membranes) 42. A 35 year old engineer was admitted for 1 month intermittent fever, anorexia, and cough which initially was dry but later productive of greenish, blood-streaked sputum. What isolation precautions should be done for this patient? a. Admission in a single room b. Wearing of gloves when taking his blood pressure c. Asking the patient to wear N95 respirator mask all the time d. Separating the patient’s utensils e. All of the above Airborne Precautions: • Airborne transmission occurs when droplet nuclei (<5 microns) are disseminated in the air and inhaled by a susceptible host • Droplet nuclei can remain suspended in the air for long periods of time and can be carried on air currents over long distances. • Recommendations – Isolation room/special ventilation room Negative air-pressure ventilation, HEPA filtered air if re-circulated Keep the door closed at ALL times – Patient should wear a mask when transported out of room – Healthcare Worker (HCW) should wear fitted respirator mask (N95 mask) Internal Medicine Ratio - 2014 Page 12 43. Contact precautions should be observed in patients with the following conditions EXCEPT a. Scabies b. Herpes zoster c. HIV-AIDS d. Hepatitis A e. Shigella Contact Precautions: • Contact transmission is the most frequent means of transmitting healthcare-associated infections • Direct-contact vs indirect-contact transmission • Apply to specified patients known or suspected to be infected or colonized with epidemiologically important organisms transmitted primarily by the contact route • Infections Requiring Contact Precautions: – Multidrug-Resistant Bacteria (MRSA, VRSA) – C. difficile diarrhea, Enteroviruses, Shigella, Hepatits A – Viral and Hemorrhagic Conjunctivitis – Cutaneous Diphtheria – Herpes simplex virus, Herpes zoster, Varicella – Impetigo, Major non-contained abscesses – Scabies – S. Aureus Cutaneous Infection • Private room, cohorting permissible • Clean, nonsterile gloves at all times • Handwashing after glove removal • Gowns at all times, unless px is continent and contact of clothing with px or environmental surfaces is NOT anticipated • Remove gloves and gowns before leaving px room 44. The most effective way of preventing the spread of healthcare associated infections is a. Admission of infected patients in single rooms b. Administration of prophylactic antibiotics to persons exposed to infected patients c. Adherence to hand hygiene d. Wearing of personal protective equipment when caring for patients e. All of the above *From 2009 Tranx: • Contact transmission is the most frequent means of transmitting healthcare-associated infections • Health Care Worker’s Hands are probably the most common means by which spread of infection by direct contact can occur, so hand hygiene is most important to adhere to. 45. In healthcare facility where single rooms are limited, patients with respiratory infections transmitted through droplets may be cohorted in a multi-bed ward as long as the beds are maintained at what distance from each other a. 3 feet b. 5 feet c. 7 feet d. 10 feet Droplets do not remain suspended in the air and travel only short distances (3 feet or less). 46. Which healthcare associated infection is the most frequently seen in the hospitals today a. Ventilator-associated pneumonia – 13% b. Catheter-related UTI – 34% c. Surgical site infection – 17% d. Vascular device-related infection – 14% e. Infected pressure sores 47. In assessing an infection related to a vascular access device, what is the most appropriate mode of doing cultures? a. Obtain two peripheral blood cultures b. Obtain cultures from each access port of the suspected line c. Obtain two cultures peripherally from two separate sites with semiquantitative cultures of the catheter tip d. Obtain a culture of skin form the exit site of the central venous catheter Culture: • Recovery of the same species of microorganisms from peripheral-blood cultures • Semiquantitative cultures of the vascular tip • Pathogens: Coagulase-negative Staphylococcus, S. aureus, enterococci, gram-negative bacilli, Candida Internal Medicine Ratio - 2014 Page 13 48. Which of the following risk factors will contribute most significantly to the development of healthcare associated pneumonia in a 65 year old male admitted stuporous for a massive stroke? a. Uncontrolled blood pressure b. Feeding through nasogastric tube c. Depressed sensorium d. Mechanical ventilation e. Age *Both C and E can be possible answers since they are both listed as risk factors. Since the cause of his stroke is not indicated and there is no indication of use of mechanical ventilation or a nasogastric tube, A, B, and D are the less likely answers. Risk Factors: • Events that increase the risk of colonization by potential pathogens – e.g. prior antimicrobial therapy, contaminated ventilatory equipment, low gastric pH • Increased risk of aspiration of oropharyngeal contents into the lower respiratory tract – intubation, decreased level of sensorium • Reduced host defense mechanisms in the lung that permit overgrowth of aspirated pathogens – e.g. COPD, old age 49. Administration of prophylactic antibiotics to prevent surgical site infections should be a. 1 hour before surgery b. 24 hours before surgery c. End after 3 days d. End on day 7 post-surgery e. Given during first incision Administer prophylactic antibiotics within 1 hour before surgery; discontinue within 24 hours. 50. Which pathogen is most commonly isolated in bloodstream infections related to the use of vascular catheters a. Pseudomonas aeruginosa b. Escherichia coli c. Candida d. Staphylococcus aureus e. Streptococcus viridians *From 2009 Tranx: • Most Common Pathogens: 1. Coagulase Negative Staphylococci 2. S. Aureus 3. Enterococci 4. Nosocomial Gram-negative Bacilli 5. Candida • Many pathogens, especially staphylococci, produce extracellular polysaccharide biofilms that facilitate attachment to catheters and provide sanctuary from antimicrobial agents • Therapy for vascular access-related infection is directed at the pathogen directed at the pathogen recovered from the blood and/or infected site. Internal Medicine Ratio - 2014 Page 14