2012 Course: Melanoma Update, Critical & Urgent Diagnoses and Alopecia

    Event Date: 
    Fri, 04/20/2012 - 08:00 - Sun, 04/22/2012 - 16:00

    Dates:

    Address: 
    City:
    Scottsdale
    ,
    Country:
    United States

    Dermpedia textbook

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    Tufts Department of Dermatology Grand Rounds

    Tufts Dermatology

    Grand Rounds is held at Tufts Medical Center on the third Wednesday of each month. Attendings and residents examine patients with more unusual skin conditions or therapeutic challenges and then discuss differential diagnoses, pathology results and management options during the Grand Rounds case discussion.

    Specialty clinics at Tufts Dermatology include patch testing, infectious disease, psoriasis and psoriatic arthritis, pediatric dermatology, connective tissue diseases, and cosmetics.

     

    Contributor(s): 

    Cases associated with this grand round:

  • 25 yo asian female with diffuse papules
    Author: Neal Kumar BA

  • 50 year-old female with hx of SLE presenting with excoriated papules and flushing
    Author: Neal Kumar

  • 20 year-old male with lesions since childhood
    Author: Neal Kumar

  • 50 year-old female with hypopigmented lesions
    Author: Neal Kumar

  • Dr. Brinster: A 54 year old man has areas of ha...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 54 year old man has areas of hair loss on the face and trunk. Biopsy shows:

     

    Routine HE

     

     

    A mucin stain:

     

     

    This condition most closely overlaps with:

    A 30 year old man develops pruritic papules on ...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 30 year old man develops pruritic papules on the back and face. A skin biopsy shows:

    This condition may be associated with which of the following conditions:

     

    Dr. Brinster: A 27 year old man has HIV and pre...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 27 year old man has HIV and presents with pink papules on the neck and trunk. Pathology shows a plasma cell-rich folliculocentric inflammatory infiltrate:

    Which of the following is the best way histologically to determine the correct diagnosis:

    Dr. Brinster: A 27 year old woman presents with...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    Dr. Brinster: A 27 year old woman presents with the following:

    The features are consistent with folliculitis decalvans. This condition histologically most closely resembles:

    Dr. Brinster: A 53 year old man has tender drai...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 53 year old man has tender draining nodules on the crown of his scalp. Biopsy shows the following:

    What is the best diagnosis:

    Dr. Brinster: A 54 year old African- American m...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 54 year old African- American man presents with a large, multinodular plaque on the occipital scalp.

    What is the best diagnosis?

    Dr. Brinster: A 54 year old African-American wo...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 54 year old African-American woman presents with a 12 year history of hair loss over the vertex of the scalp.

    Biopsy reveals the following features: perifollicular lymphocytic infiltrate, concentric lamellar fibrosis (layers of fibroblast in papillary dermis), sebaceous gland loss and premature disintegration of the internal root sheath.

    What is the most likely diagnosis?

    Dr. Nooshin Brinster: Actue generalized eczematous pustulosis

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 21 year old woman is hospitalized with an acute onset pustular eruption on her face, neck and trunk. It began 2 weeks after starting amoxicillin for a sinus infection.

     

    Biopsy shows acute spongiotic and pustular dermatitis with eosinophils. Which is the most fitting diagnosis?

    Dr. Brinster: A 34 year old woman with a history of inflammatory bowel disease

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 34 year old woman with a history of inflammatory bowel disease is referred by her gynecologist for treatment of severe inguinal candidiasis.  The biopsy showed non-necrotizing "sarcoidal" granulomas and no evidence of microorganisms on special stains. 

     

    What is the most likely diagnosis?

    Dr. Brinster: A 57 year old man is status post ...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    A 57 year old man is status post renal transplant and has firm, bound down skin of the extremities. A biopsy is done for new onset nodules on the right hand. Histology shows expansion of deep dermal fibrous tissue with increased number of spindle cells. You consider a diagnosis of nephrogenic systemic sclerosis. 

     

    Which of the following stains would be most helpful in conforming the diagnosis?

    Dr. Brinster: 27 year old woman presents with j...

    Multiple choice question

    Question provided by Dr. Nooshin Brinster, M.D.

    27 year old woman presents with joint pain and a rash on her back.  The rash is comprised of erythematous papules with slight scale in a variably linear distribution.

      

     The biopsy shown below revealed neutrophilic urticaria. 

     

     

     

    What is the best diagnosis?

    Dr. Magro: Hemorrhagic edema of infancy (altern...

    Multiple choice question

    Question provided by Dr. Cynthia Magro, M.D.

    Hemorrhagic edema of infancy (alternative designations include: Finklestein’s disease, Seidlmayer syndrome and postinfectious cockade pupura) is a benign leukocytoclastic vasculitis seen in infants.  Infants affected are usually  between two months and two years old  although there are some documented cases of outbreaks at the age of three.

     There is a high male to female ratio at 4.64 to 1 (1).   

    A classic case of hemorrhagic edema of infancy is illustrated below:







    IgA immunoflourescence:

     
    Which statement regarding this condition is INCORRECT 
     

    Dr. Magro: Although not part of a routine pract...

    Multiple choice question

    Dr. Magro:
    Although not part of a routine practice, the skin biopsy has been used  in evaluation of neurologic disease including small fiber neuropathy. The images below shows cutaneous innervation on thick sections. This method may allow assessment of small nerve loss in possible small fiber neuropathy

    Which of the following is a correct statement about small fiber neuropathy?

     

    Dr. Magro:Drug-associated lymphomatoid reacti...

    Multiple choice question

     

    Question provided by Dr. Cynthia Magro, M.D.
    Drug-associated lymphomatoid reactions from a light microscopic, phenotypic and molecular perspective the lesions resemble T or B cell lymphoma. The clinical presentation can mimic lymphoma. In some but not all cases a drug association is established based on resolution following drug cessation and or a temporal association with commencement of drug therapy.  
    With appropriate drug modulation the clinical course is benign, namely no progression, one of resolution and no recurrence.
     
    The images below show a clinical example of a lymphomatoid drug eruption and biopsies.







     

    Which of the following statements is  CORRECT  about drug induced pseudolymphoma?
        

     

    Dr. Magro: Which of the following statements is...

    Multiple choice question

    Question provided by Dr. Cynthia Magro, M.D.

    Which of the following statements is true  about Rowell’s syndrome?

    Dr. Magro: Lymphocytic vasculitis of the skin h...

    Multiple choice question

    Question provided by Dr. Cynthia Magro, M.D.

    Lymphocytic vasculitis of the skin has varied etiologies. It is important to evaluate the sample for eosinophils as the presence of a lymphocyte mediated vasculitic reaction associated with tissue eosinophilia is typically the sequelae of a type IV immune reaction including one of drug based etiology and or attributable to a potent epicutaneous stimulus such as an athropod.

    In contrast, lymphocytic vasculitis unaccompanied by tissue eosinophilia can be linked with viral syndromes and collagen vascular disease. 
     
    The clinical image and the biopsy below is from a young male patient with clinically suspected pernio/chilblains.
     



     
    The 2 clinical pictures below are from 2 different patients.
    Patient  A is a 3 year old female with chilblains/severe neurologic impairment ( Aicardi Goutiere syndrome)

     Patient B has familial  perniosis (Prendiville, Crow JAAD 2009) 



     

     

    Both patients have been established to have 3 5 DNA exonuclease TREX1 mutation

    Found on chromosome 3p, this defective exonuclease leads to excessive levels of DNA derived nucleic acids triggering interferon alpha, a potent activator of  both the innate/adaptive immune response.  

    Patients with AGS may have family members with perniosis

     Which statement regarding perniosis is CORRECT  in reference to the  collage presented? 







     

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