Dermatology

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. Oculocutaneous albinism

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. 5. This patient has an abnormal chest x-ray.

What is the most likely diagnosis?

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 Intravenous benzylpenicillin + flucloxacillin

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 lipoidica diabeticorum Correct

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. Chlorpromazine may be associated with the development of drug-induced lupu

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 twoweek 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) Emolient baths and ointments

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.

18.

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, flattopped 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 coexisting 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 epidermis.

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 wellcircumscribed, 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.

27.

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.

28. This 28-year-old female presents with this appearance of her legs.

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.

29.

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.

30.

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. What is the most appropriate treatment to start?

(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. What treatment would you offer him?

(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) 9 White cell count 6.1 x10 /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