(BMJ) – An 82-yo man presented w/ acute onset throat pain and dysphagia upon wakening. His wife recalled him suddenly beginning to snore the night before. PMHx: A-fib. Meds: warfarin. Labs: INR 3.4. What is the diagnosis?
Strep pharyngitis
Oropharyngeal cancer
Uvular hematoma
Behcet syndrome
Aphthous ulcers
You are correct. This patient had a uvular hematoma secondary to anticoagulation. Symptoms improved after warfarin was stopped and dexamethasone was initiated. This case highlights the importance of considering airway hematomas among the differential dx in pts presenting w/ sx suggestive of upper airway obstruction. The acute onset of snoring also should not be ignored.
(BMJ) – A 48-yo woman presented with a presumed verruca on the underside of her second toe. The lesion had not responded to topical or oral antibiotics and was acutely tender, macerated, and hyperkeratotic. What is it?
Squamous cell carcinoma
Tinea pedis
Acral lentiginous melanoma
Spider bite
Prurigo nodularis
You are correct. Histologic examination revealed an invasive, well-differentiated squamous cell carcinoma (SCC) w/ a tumor thickness of 4.7 mm. Toe amputation was necessary for complete excision. The warty morphology of SCC on the sole may lead to misdiagnosis as verruca vulgaris. Urgent investigation is needed if there is any clinical uncertainty.
(BMJ) - A 91-yo woman w/ a family hx of breast cancer presents w/ redness of left breast and nipple x 1 yr. Exam: red, crusty nipple-areolar complex w/ nipple destruction. A 4-wk trial of steroid cream did not lead to improvement. What is the diagnosis?
Actinic keratosis
Impetigo
Paget disease
Eczema
Malignant melanoma
You are correct. Paget disease of the nipple is a rare form of breast carcinoma. Core bx and nipple skin bx confirmed ductal carcinoma in situ w/ Paget disease. The pt had a left mastectomy. Suspicious features of Paget disease include presentation at age >50, nipple-areolar complex involvement, nipple destruction, and no improvement from a 4-wk trial of steroid cream.
(BMJ) - An 82-yo man c/o 10 days of pain and color change in his tongue associated w/ a headache. Exam: grey-black discoloration of distal tongue and scalp tenderness. Labs: elevated inflammatory markers. What is the diagnosis?
Syphilis
Methamphetamine abuse
Oral melanoma
Necrotizing ulcerative gingivitis
Giant cell arteritis
You are correct. Giant cell arteritis (GCA) is the most common cause of tongue necrosis. The patient was started on high-dose oral corticosteroids and a temporal artery biopsy confirmed GCA.
(BMJ) - A 20-yo female horse rider presented w/ painful lesions on her outer thighs during winter for 5 yrs. Exam: red, indurated, tender plaques on lateral thighs. Labs: vasculitis screen, serum cryoglobulins, and cold agglutinins all normal. What is the diagnosis?
Frostbite
Lichen planus
Tinea corporis
Erythema chronicum migrans
Equestrian perniosis
You are correct. Equestrian perniosis (EP) occurs on the thighs and buttocks of female horse riders in cold weather. In this patient, skin biopsy from the affected area confirmed perniosis w/ lymphocytic vasculitis. Wearing warm, loose clothing, avoidance of cold, and use of oral nifedipine or pentoxifylline may be helpful.
(BMJ) - A 7-yo boy presented w/ a rash on his chin, cheeks, and nose x 2 mos. Thinking it was eczema, his mother applied triamcinolone cream. The rash improved initially, but then returned and spread. Exam: monomorphic erythematous papules. What is it?
Impetigo
Periorificial dermatitis
Folliculitis
Prepubertal acne
Candidiasis
You are correct. Periorificial dermatitis, also known as perioral dermatitis, is a common benign condition. Lesions are 1- to 2-mm, skin-colored to erythematous monomorphic papules on the perioral region, nose, cheeks, and/or periocular region. Pustules are not typical of this condition. Patients may c/o mild pruritus and lesions can be chronic. Known triggers include chronic topical steroid use, including those that are inhaled via a mask. Patients should discontinue all steroids if possible, including OTC preparations. Tx includes metronidazole 0.75% cream, or oral tetracyclines or macrolides.