AIIMS Nov 2015- Dermatology solved questions

There were 11 questions in all- 

1)A Lady with asymptomatic pearly small nodules on forehead since 2 months. 2 year daughter also has similar lesion. Causative agent?
HPV
Coxsackie
Pox
Papilloma virus

Answer: Pox virus (this is molluscum)

expl: 

Etiology: Molluscum contagiosum is caused by up to four closely related types of poxvirus, MCV­1 to 4 and their variants. MCV­1 infections are most common (MCQ). In patients infected with HIV, however, 

MCV­2 causes the majority of infections (60%) (MCQ). Immunosuppression, either systemic T­cell immunosup­pression (usually HIV, but also sarcoidosis and malignancies) or abnormal cutaneous immunity (as in atopic dermatitis or topical steroid use), predisposes the individual to infection. 

Virtually all   HIV­infected patients with molluscum contagiosum already have an AIDS diagnosis and a helper T­cell count of less than 100

Morphology: Individual lesions are smooth ­surfaced, firm, dome ­shaped, pearly papules (remember these words), averaging 3–5 mm in diameter. 

Complications: Irritated lesions may become crusted and even pustular. Dermatitis surrounding a lesion 

usually heralds the resolution of that lesion (called Meyersons phenomenon)

2) Nodulocystic acne in a young boy with oily skin. Treatment
Oral isotretinoin
Topical adapalene
Answer: Oral Isotretinoin

3) 18 year female (visual below) with hypopigmented patch in both ankle what is not used for treatment -

Topical clobetasol
Topical tretinoin
Topical tacrolimus
Topical methoxasalen
Answer: B

4) Hypoanesthetic patch. Thickened ulnar nerve diagnosis. Histopathology given
TT
LL
lymphoma
Histiocytosis
Answer: TT

5) Athletic Male with itchy lesion at groin. causative agent is A/E
trichopyte
Micro
Epidermo
Aspergillus
Answer: aspergillus

6) Lady with bilateral buccal reticulate white streaks. Pain increase on spicy food intake and pt give no h/o tobacco but show amalgam on 3rd molar
A. Lichen planus
B. Leukoplakia
C. Aphthous stomatitis
D. Candida
Answer: LP

7) oral candidiasis presents with white patch in all except?
a. acute pseudomembranous candidiasis
b. Acute atrophic candidiasis
c. chronic hyperplastic candidiasis
d. chronic mucocutaneous candidiasis
Answer: B (also called as antibiotic tongue. It is red)

8) A 20 yr old pt with neurocysticercosis develops generalised peeling of skin (except palms and soles) and severe oral and genital involvement starting one month after taking medications for seizures. Diagnosis is
a. SJS
b. TEN
c. Fixed drug eruption
d. Pemphigus vulgaris
Answer: TEN

9) A kit of drugs(visual below) with 30 tab alternate white and brown separate tab.
A..leprosy
B..urethral discharge
C..vaginal discharge
D..hiv n aids
Answer: Leprosy

10) ulcer smear visual in comments
-klebsiella granulomatis

STD guidelines in pregnancy (CDC 2015)

Schamberg's disease

Schamberg's disease (Progressive pigmented purpuric dermatoses) 

• Capillarits of unknown etiology seen in  young adults
• Commonest site is legs
• Asymptomatic
• The commonest type of capillaritis seen
• Gravity and increased venous pressure are important in etiology
• A true vasculitis is not seen on skin biopsy. Blood cells pass through small gaps that arise between the endothelial cells, which make up the capillary walls. The result is tiny red dots appear on the skin, described as cayenne pepper spots. They group together to form a flat red patch, which becomes brown due to hemosiderin deposition in the skin. 
• The disease follows a chronic course with spontaneous clearance in a few cases. 
• Treatment modalities which have been used include topical and systemic corticosteroids, vitamin C and topical and systemic anti inflammatory agents. Pentoxifylline, a methylxanthine derivatice, has been used successfully in treatment. Leg elevation and compression stockings also help

Lupus band test

Lupus band test (LBT)

It is a diagnostic procedure that is used to detect deposits of immunoglobulins and complement components along the dermoepidermal junction in patients with lupus erythematosus (LE).

The LBT is positive in about 70%–80% of sun-exposed skin in pts with systemic LE (SLE), and in about 55% of SLE cases in non sun exposed skin. It is demonstrable as a linear band at the basement membrane zone on immunofluorescence tetsing. All major immunoglobulin classes (IgG, IgM, and IgA) and various complement components have been identified in these DEJ deposits. The test is done on the skin biopsy, usually with direct immunofluorescence staining. The most frequent immunoglobulin class deposited is IgM, which is seen in about 90% of lesional skin biopsies, whereas the least frequently seen class is IgA.

A positive LBT may serve as a prognostic indicator in patients with an established diagnosis of LE, as it correlates with severe extracutaneous disease, mainly lupus nephritis, and with anti-dsDNA antibodies. The usefulness of the LBT as a diagnostic procedure in LE patients is also well established. The positive result of this test within the uninvolved skin is a strong indicator of LE.

Collodion baby

2015 new CDC STD guidelines

Classification of topical corticosteroids

 Topical corticosteroids have been ranked in terms of potency into four groups consisting of seven classes. Class I topical corticosteroids are the most potent and Class VII are the least potent. Efficacy and side-effects are greatest with the Class I ultra-high-potency preparations which should only be used for limited time periods (2-3 weeks)

----ULTRA HIGH POTENCY

      Class I

Clobetasol propionate Cream, 0.05%

------HIGH POTENCY

        1)  Class II

Amcinonide Ointment, 0.1%

Betamethasone dipropionate Ointment, 0.05%
 

Desoximetasone Cream or ointment, 0.025%

Fluocinonide Cream, ointment or gel, 0.05%
 

Halcinonide Cream, 0.1%

        2)  Class III

Betamethasone dipropionate Cream, 0.05%

Betamethasone valerate Ointment, 0.1%
 

Triamcinolone acetonide Ointment, 0.1%

-----  MODERATE POTENCY

        1) Class IV

Desoximetasone Cream, 0.05%

Fluocinolone acetonide Ointment, 0.025%
 

FludroxycortideOintment, 0.05%

Hydrocortisone valerate Ointment, 0.2%
 

Triamcinolone acetonide Cream, 0.1%

      2) Class V

Betamethasone dipropionate Lotion, 0.02%

Betamethasone valerate Cream, 0.1%

Fluocinolone acetonide Cream, 0.025%
 

FludroxycortideCream, 0.05%

Hydrocortisone butyrate Cream, 0.1%
 

Hydrocortisone valerate Cream, 0.2%

Triamcinolone acetonide Lotion, 0.1%

------------LOW POTENCY

        1) Class VI

Betamethasone valerate Lotion, 0.05%

Desonide Cream, 0.05%
 

Fluocinolone acetonide Solution, 0.01%

       2) Class VII

Dexamethasone sodium phosphate Cream, 0.1%

Hydrocortisone acetate Cream, 1%
 

Methylprednisolone acetate Cream, 0.25%

DRESS syndrome

DNB 2013

DRESS syndrome is associated with all except
a.Drug reaction
b.myocarditis
c.Eosinophilia
d.Encephalitis
Ans: d

DRESS syndrome- Short synposis

•Initially, 'anticonvulsant hypersensitivity syndrome' was first used to label this specific entity.

•Drug hypersensitivity syndrome (DHS) also referred to as DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) term is now used.

•It is an adverse drug reaction commonly associated with the aromatic antiepileptic drugs viz., phenytoin , carbamazepine , phenobarbital , lamotrigine, primidone etc. It may also be seen with Allopurinol, Dapsone, Minocycline, Nevirapine

•It is usually defined by the triad of fever, skin rash and symptomatic or asymptomatic internal organ involvement, within the first 2-8 weeks after initiation of therapy.

•Skin manifestation are in the form of exanthem, erythroderma or blisters. Internal manifestations include, among others, agranulocytosis, hepatitis, nephritis and myocarditis.

•Management mainly includes immediate withdrawal of the culprit drug, symptomatic treatment and systemic steroids or immunoglobulins.

Features for DRESS are as below: 

Partner management of STDs (CDC Guidelines)

Partner management of STDs 
(CDC Guidelines)

STD	Yes/No	Comments
Syphilis	Yes	- Partners to be treated if exposure within last 90 day before onset of pts symptoms (if early, secondary and early latent syphilis in the patient. VDRL > 1:32 indicates patient is in early syphilis stage) - If exposure >90 days before onset of pts symptoms should be offered serology and if not possible, treat presumptively
Chancroid	Yes	Partners to be treated if exposure within last 10 day before onset of pts symptoms
Donovanosis	Yes	Partners to be treated if exposure within last 60 day before onset of pts symptoms
LGV	Yes	Partners to be treated if exposure within last 60 day before onset of pts symptoms
Chlamydia/ Gonorrhea (generally treated together)	Yes	Partners to be treated if exposure within last 60 day before onset of pts symptoms
Trichomonas	Yes	Partner treatment is always done (time before exposure to patient not specified)
PID	Yes	Partners to be treated if exposure within last 60 day before onset of pts symptoms
Epididymitis	Yes	Partners to be treated if exposure within last 60 day before onset of pts symptoms
Genital Scabies	Yes	Partners to be treated if exposure within last 30 day before onset of pts symptoms
Herpes genitalis	No	Partners evaluated for active disease, Asymptomatic partners NOT treated
Bacterial Vaginosis	No	NOT required
Candida	No	Treatment NOT done for asymptomatic partners as most infections are not sexually transmitted. Only for symptomatic male  partners with erythema, pruritus and irritation on glans

Acantholysis

Introduction

• The term acantholysis  is derived from the Greek words akantha, meaning a thorn or prickle, and lysis, i.e. loosening.
• Acantholysis is the term used to describe loss of cohesion between  keratinocytes, due to breakdown of intercellular bridges (eg- Desmosomes). This makes the normally polygonal keratinocytes  circular (Circular keratinocytes= Acantholytic cells). It results in the formation of intraepidermal clefts, vesicles and bullae.

Although acantholysis may occur at any level of the epidermis, the location of the blister is often used as a clue to the underlying disorder; for example, superficial (subcorneal) acantholysis favors pemphigus foliaceus, while acantholysis in the deeper aspects of the epidermis is more characteristic of pemphigus vulgaris

Acantholytic cell in pemphigus- Yellow arrow
(Ref: IJDVL. Seshadri et al.)

Primary Acantholysis

Acantholysis is either due to direct injury to desmosomes (eg: Pemphigus, bullous impetigo, staphylococcal scalded skin syndrome SSSS) or due to hereditary defects in their construction (eg: Darier's disease and Hailey-Hailey disease). Thus, in these diseases, acantholysis is the primary event leading to the formation of intra-epidermal cavities and hence the manifestations of the disease.  Eg: pemphigus, Darier’s disease etc 

Secondary Acantholysis

The acantholysis is secondary to alteration or damage to keratinocytes by various factors. In other words, keratinocytes are injured first followed by subsequent disintegration of desmosomes. Eg: In herpes, intraepidermal vesicle is secondary to ballooning degeneration of keratinocytes causing circular keratinocytes. Tzanck cells are multinucleated giant cells seen after fusion of individual acantholytic cells and is characteristically seen in herpes.

MCQs

1) A middle aged female presents with flaccid bullae in skin and oral erosions. Histopathology shows intra-epidermal acantholytic blisters. The most likely diagnosis is (PGI 05)

a) Pemphigus vulgaris

b) Bullous pemphigoid

c) Dermatitis herpetiformis

d) Epidermolysis bullosa

e) Pemphigus foliaceous

Ans: a

2) A female presents with persistent painful oral erosions with acantholytic cells. Most likely diagnosis (AI 08)

a) Dermatitis herpetiformis

b) Bullous pemphigoid

c) Pemphigus vulgaris

d) Epidermolysis bullosa

Ans: c

3) Acantholysis is seen in (PGI 99)

a) Bullous pemphigoid

b) Dermatitis herpetiformis

c) Hailey-Hailey disease

d) Darier’s disease

e) Pemphigus vulgaris

Ans: c.d.e

4) Acantholysis is seen in (AI 95)

a) Epidermis

b) Dermis

c) Dermoepidermal junction

d) Subcutaneous tissue

Ans: a

5) Acantholysis is due to destruction of (AIIMS 97)

a) Epidermis

b) Dermis

c) Basement membrane

d) Intercellular susbstance

Ans: d

6) Acantholytic cells are (SGPGI 01)

a) Epidermis cells

b) Plasma cells

c) Keratinocytes

d) Giant cells

Ans: c

7) Acantholytic cells are (PGI 96)

a) Cells with hyperchromatic nuclei and perinuclear halo

b) Cells with hypochromatic nuclei and perinuclear halo

c) Multinucleate cells

d) None

Ans: a

8) A 50 year old man with flaccid bullae and oral ulcers. Smear from skin lesions would show (AI 96)

a) Tzanck cells

b) Acantholytic cells

c) Necrosis

d) Koilocytes

Ans:b