Self-Assessment examination of theAmerican Academy of Dermatology*

Identification No. 886-203

Instructions for Category Sed) CME credit appear in the frontadvertising section. See last page of Contents for pagenumber.

Instructions: In answering each question, refer to the specificdirections provided. Since it is often necessary to provideinformation in questions occurring later in a series that giveaway answers to earlier questions, pleaseanswer the questionsin each series in sequence.

QUESTIONS 1-10

A 42-year-old male truck driver who traveledto San Francisco from Miami, FL, hauling vege­tables developed a pruritic, erythematous, follic­ular, papular and pustular rash on his back, chest,upper arms, and thighs during July 1982 (Fig. 1).

1. Your differential diagnosis should include (Answeras many as apply. All, some, or none ofthe choicesmay be correct.)a. miliaria rubrab. scabies infestationc. Pityrosporum folliculitisd. acne vulgarise. Pseudomonas folliculitis

He was examined by his family physician who,after a trial of systemic antibiotics, treated himwith prednisone, 60 mg by mouth per day.

The Self-Assessment examination is supported inpart by an educational grant from OWEN Labo­ratories, Fort Worth, TX.

The new and continuing members of the Self-Assessment Committeeof the American Academy of Dermatology are: Emesto Gonzalez,M.D., chairman, William A. Anderson, M.D., Rita Berman,M.D., Mark Bernhardt, M.D., Fred F. Castrow II, M.D., RichardL. De ViIlez, M.D., Barbara A. Gilchrest, M.D., Gloria Graham,M.D., Francisco Kerdel, M.D., Donald Lookingbill, M.D.,Marilynne McKay, M.D., Sharon Raimer, M.D., Steven Spencer,M.D., and Kenneth Tomecki, M.D.

*This examination was prepared by the following members of theCommittee: W. Clark Lambert, M.D., chairman, Joseph B.Bikowski, M.D., Fred F. Castrow II, M.D., Richard L. De ViIlez,M.D., Barbara Ann Gilchrest, M.D., Emesto Gonzalez, M.D.,Ira H. Gouterman, M.D., Terry M. Jones, M.D., MarilynneMcKay, M.D., Thomas G. Olsen, M.D., Richard K. Scher, M.D.,Thomas R. Wade, M.D., and Paul S. Wolfish, M.D.

JOURNAL of theAmeRiCaN ACaDemy OF

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2. After 8 months on prednisone, doses ranging from20 to 80 mg/day, to control the pruritus, you mightexpect to find (Answer as many as apply. All, some,or none of the choices may be correct.)a. hypertensionb. moon faciesc. muscle weaknessd. striaee. cataracts

3. The patient was referred to you for consultation.Your evaluation of the patient would include (An­swer as many as apply. All, some, or none of thechoices may be correct.)a. scraping of pustules and microscopic exami-

nation ·in oil under a coverslip for scabiesb. culture of a pustulec. skin biopsyd. microscopic examination of a gram-stained

specimen from a pustulee. microscopic examination of a potassium hy­

droxide (KOH) preparation from a pustuleThe oil preparation for scabies was negative.

The KOH preparation revealed round and buddingyeast and occasional broad, short hyphae. Cultureand Gram's stain from the pustules were negativefor bacteria. Skin biopsy revealed a dilated hairfollicle with keratinaceous debris admixed withunipolar budding yeast forms. An infiltrate ofneu­trophils and macrophages was present around theintact follicle.4. Your best diagnosis is (Choose the single best re­

sponse.)a. miliaria rubrab. scabiesc. Pityrosporum folliculitisd. keratosis pilarise. Pseudomonas folliculitis

5. The predisposing factors for the inception and con­tinuation of the infection in this case were (Answeras many as apply. All, some, or none ofthe choicesmay be correct.)a. broad-spectrum type antibiotic therapyb. humid, hot environment in a non-air-condi­

tioned truck

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28A Self-Assessment examinationJournal of the

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c. systemic corticosteroid therapyd. excessive ethanol intakee. occult malignancy

6. While decreasing the patient's systemic corticoste­roid medication, several forms of therapy are ap­propriate for treating Pityrosporum folliculitis.These include (Answer as many as apply. All,some, or none of the choices may be correct.)a. topical imidazolesb. salicylic acid and benzoic acid in hydrophilic

basec. sodium thiosulfate and salicylic acidd. Selenium sulfide 2.5% lotione. systemic ketoconazole

The patient was treated with topical medica­ments for 2 months without success. He wastreated with oral ketoconazole, 200 mg per day,

for 14 days. On the fourteenth day of therapy thepatient complained of upper right quadrant painand discolored urine. Your examination revealedscleral icterus, an enlarged liver on palpation, andbile in the urine. The serum transaminase and al­kaline phosphatase levels were elevated.

7. The cause of this patient's signs and symptomscould be (Answer as many as apply. All, some, ornone of the choices may be correct.)a. infectious hepatitisb. alcoholic hepatitisc. hepatic metastasis from occult malignancyd. acute cholangiitis with ampulla of Vater ob­

structione. hepatic reaction to ketoconazole

8. Hepatic reactions to ketoconazole are characterizedby all of the following, except (Choose the singlemost appropriate response.)

30A Self-Assessment exammatlOn

a Ictenc sIgns (jaundIce and/or dark unne, palestools)

b amctenc symptoms (fever, malaIse, anoreXia,nausea, vomItIng)

c occurs more commonly m womend mfrequent cause of deathe does not recur wIth retreatment

9 Other commonly used drugs that can cause a sIlentor symptomatIc hepatIc reactIon mclude (Answeras many as apply All, some, or none o/the ChOlceSmay be wrreLl )a dIazepamb methyldopac qUlOidmed phenothIazmese phenobarbItal

10 SymptomatIc hepatIc reactlOns to ketoconazole arethought to occur In approXImately (Choose the Sln­gle best response )a one per 100,000 patients takmg the drugb one per 10,000 patIents takIng the drugc one per J ,000 patIents takmg the drugd one per 100 patients takIng the druge 10% of patients takIng the drug

QUESTIONS 11-23

A 23-year-old graduate student In archeologyconsults you for two nonheahng "bOlls" on thedorsal aspect of the wnst The patIent was treated6 weeks prevIously WIth pemcIlhn The leSIOnsImproved only shghtly The exammatIOn revealstwo cratenform plaques over the dorsal aspect ofthe left wnst Nodes m the left axIlla are palpable

11 At thIS pomt In the workup you should (Choosethe smgle best response)a take a more thorough hIStOryb obtam a skIn bIOpSy speCImenc culture the lesIOns for bactena and deep fungId obtam a complete blood count and erythrocyte

sedImentatIOn ratee obtam a computer-assIsted tomographIc (CAT)

scan of the head and chest

12 You learn that the patIent was In Israel 3 monthsprevIOusly on an archeologic dIg You obtam abIOpSy of the leslOn (FIg 2) The most lIkely dI­agnosIs IS (Choose the smgle best response)a Amencan leIshmamasIsb Onental lelshmamasisc malarIad onchocercIasIse blastomycosIs

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13 The orgamsm responsIble for Onental leIshman­IaSIS IS (Choose the ~mgle best response)a Lelshmama donovamb Lel~hmama troplcac Lelshmanza brazlhenslsd Lelshmama kala-azare Treponema pailldum

14 DIseases In WhICh bIOPSY reveals paraSItIzed hIStI­ocytes mclude all of the follOWIng, except (Choosethe smgle most approprzate response)a rhmoscleromab chancrOIdc granuloma mgumaled hIstoplasmosIse leIshmamasIs

15 The speCIal stam of chOice to better highlIght thedIagnostic paranuclear rodhke structure, the kI­netoplast, 10 Onenta11eIshmamaSIS IS (Choo~e theszngle best response)a crystal VIOletb collOIdal Ironc GIemsad tolUidme bluee penodlc aCId-SchIff (PAS)

16 A skm test m leishmamasis IS (Choose the sznglebest response )a helpful only If the patient reSIdes m an endemIC

areab helpful only If the patIent does not reSIde In an

endemIC areac the FreI testd the MItsuda teste an mducer of the HerxheImer reactIOn

17 Old World (Onental) 1elshmamasIs IS transmIttedby the bIte of the (Choose the smgle best response)a mosqUItoblousec sandflyd ticke dog

18 The treatment of chOice for cutaneOUll lelshman­laSIS IS (Choose the szngle best response)a pentavalent antIillomalsb amphotencm Bc cryosurgeryd electrosurgerye mtralesIOnal sterOIds

DzrectlOns for questzons 19-23 For each num­bered questlOn, choose the smgle be~t lettered re­sponse

Volume 14Number 3March, 1986

Self-Assessment examination 33A

a. Oriental leishmaniasisb. Kala-azarc. Bothd. Neither

19. In an immunocompetent host, is usually confinedto localized areas of the skin and draining lymphnodes

20. May be caused by the organism Leishmania don­ovani

21. May be caused by the organism Leishmania bra­ziliensis

22. May be contracted in various parts of India23. Histologically, organisms with a small rodlike

structure, the kinetoplast, are seen within histio­cytes in lesional tissue

QUESTIONS 24-28

Your next patient is a 45-year-old black womanwho noted progressive enlargement of a nODtendernodule on her left thigh for the preceding 2 years.Examination reveals a firm, 1.2 X 2-cm, induratednodule with a central depression and peripheralhyperpigmentation (Figs. 3 and 4).

24. Your differential diagnosis should include all of thefollowing, except (Choose the single most appro­priate response.)a. desmoplastic trichoepitheliomab. mestastatic adenocarcinomac. granular cell tumord. dermatofibrosarcoma protruberanse. neurilemmoma

Histopathologic evaluation reveals a dermal tu­mor consisting of many large, pale tumor cells inclusters surrounded by strands of collagen. Faintgranules are present within the tumor cells. Theoverlying epidermis is hyperplastic.

25. The most likely diagnosis is (Choose the singlebest response.)a. desmoplastic trichoepitheliomab. metastatic adenocarcinomac. granular cell tumord. dermatofibrosarcoma protruberanse. neurilemmoma

Fig. 5 shows a more typical case of this tumor,which may be, but often is not, ulcerated.

34A Self-Assessment exammatlOn

26 All of the followmg statements regardmg granularcell tumors are correct, except they (Choose thesmgle most appropnate response )a are found on the tongue In over 50% of casesb are most common m black female patientsc occur as multiple pnmary leSIOns m less than

25% of casesd contam a pustulO-OVOld body of MIlIane frequently present WIth pseudoepIthehomatous

hyperplaSIa that may mumc squamous cell car­cmoma

27 Granular cell tumors have been recorded to occurm (the) (Answer as many as apply All, some, ornone of the chOIces may be correct )a external audItory canalb salIvary glandsc tracheobronchIal treed colone pItuItary stalk

28 ImmunohIstochemIstry of a granular cell tumorcharactenstIcalIy reveals the presence of (Answeras many as apply All, some, or none ofthe choIcesmay be correct)a S-lOO protemb carcInoembryomc antIgenc penpheral nerve myelm protemd myoglobme myosm

QUESTIONS 29-35

A 4-year-old female ChIld, otherWIse healthy,presents at your office WIth a 48-hour prodromeof low-grade fever, malaise, and scattered leSIOnsof the mouth and legs (FIg 6*) ExammatlOn re­veals a fever of 37 40 C and ml1d mgumal ade­nopathy The oral lesIOns conSIst of superfiCIal ero­SIOns, surrounded by a nm of erythema, mvolvmgthe buccal mucosa, tongue, and hard palate Thepostenor aspect of the pharynx IS clear On thesoles and lateral aspects of the toes there are ap­proxImately twenty randomly scattered erythem­atous papules and veSIcles There IS extenSIOn tothe lower legs bIlaterally A solItary leSIOn IS notedon the dIstal tIp of the nght thumb

29 Your dIfferential dIagnOSIS should mclude (Answeras many as apply All, some, or none ofthe chOIcesmay be correct )

*Courtesy Gary D Palmer, M D , Dayton, OH

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a hand-foot-and-mouth dIseaseb varIcellac erythema mfectlOsumd herpes SImplexe erythema multIforme

30 You perform a bIOpSy (FIg 7) The correct dIag­nOSIS IS (Choose the smgle best response)a mononucleosIsb herpes SImplexc hand-foot-and-mouth dIseased erythema mfectlOsume VarIcella

31 The most common causal orgamsm for thIS syn­drome IS (a) (Choose the smgle best response)a CoxsackIe A-16 Virusb CoxsackIe A-9 VlfUSC Herpes VIruS groupd SpIrochete, Treponema pallidume Bactenum, KlebSIella group

32 The most common tIme of the year for thIS dIseaseto appear IS (there IS) (Choose the smgle best re­sponse)a spnngb summerc falld wmtere no seasonal predIlectIOn

33 All of the followmg can be used as adjunctIvedIagnostic aIds, except (Choove the ~mgle mostappropriate response)a VIral culture of mouth leSIOnb VIral culture of skm leSIOnc VIral culture of fecesd VIral culture of conjunctIvae serum of acute and convalescent antIbody tIter

(Proceed to back of answer sheet)

34 You tell the patient's parents to expect, m a weekto 10 days, (a) (Choose the smgle best response)a complete resolutIOn of the Illnessb otItIS mediac menmgItIsd dIarrheal syndromee arthntIs

35 The treatment of chOIce for thIS dIsease ISa tetracyclmeb pemctlhnc erythromYCInd sahne mouthwashese acyclOVIr