Self-Assessment

Self-Assessment examination of theAmerican Academy of Dermatology* Identification No. 893-205

Learning objectives:At the conclusion of this self-assessment learning activity, physician participantsshould be able toassess their owndiagnosticand patient managementskills with respect to thoseof their colleagues in the field, use theresults of the self-assessmentto helpdeterminepersonallearningneedsthat can be addressedthrough subsequent CMEinvolvement, and enhance their abilityto complywith the requirementsfor certification in the specialty of dermatology.

Instructions for CategoryI CME credit appear in the front advertisingsection. See lastpage of Contents for page num­ber.

Instructions: In answering each question, refer to the specific directionsprovided. Becauseit isoften necessaryto provideinformation in questionsoccurring later in a series that give away answersto earlier questions, please answer the ques­tionsin each series in sequence.

QUESTIONS 1-10

A 38-year-old man with insulin-dependent dia­betes underwent renal and pancreatic transplanta­tion and later developed a relapse of his kidney dis­ease. Several months after he began dialysis, dome­shaped hyperkeratotic papules developed on thearms, legs, and dorsal aspects of the feet (Fig. 1).Although the lesions were only slightly pruritic, heoften scratched outthe "cores" and produced a smallamount of bleeding. Histopathologic evaluation re­vealed an epidermal invagination filled with degen­erated basophilic material and keratin (Fig. 2).

1. The best diagnosis is (Choose single best response.)a. prurigo nodularisb. hypertrophic lichen planusc. acquiredperforating disorderd. dermatofibrosis lenticularis disseminatae. phyrnoderma

2. The clinical differentialdiagnosis includeseachofthefollowing except (Choose single best response.)a. multiple eruptive keratoacanthomasb. reactiveperforating collagenosisc. hyperkeratosis lenticularisperstansd. pityriasis rubra pilarise. lichen striatus

3. Acquiredperforatingdermatosishas beenassociatedwith (Choose two best responses.}a. diabetes

I)oc.TheSelf-Assessment examinationissupportedinpart byanr~ educationalgrant from the Procter & Gamble Company,

Cincinnati, Ohio.

*Members of the Self-Assessment Committee of the American Acad­emy of Dermatologyare:Kenneth J. Tomecki, MD, chairman, Bur­ton S. Belknap, MD, Mary R. Buchness, MD, Ponciano D. Cruz.MD, C. RalphDanielIII, MD, Gary R. Kantor, MD, Francisco A.Kerdel,MD, TobiB. Richman, MD,TheodoreRosen,MD, RobertA. Schwartz, MD, Norman W. Walton III, MD, and Ronald G.Wheeland, MD.

b. renal failurec. granulomatous rosacead. angiosarcomae. acne

4. Lesionsare most commonly (Choosesingle best re­sponse.}a. found in menb. present on the extensor aspect of the legs and feetc. prominent on the backs of the fingersd. arranged in a follicular patterne. associatedwith arsenic ingestion

5. The Koebnerphenomenoncan occur in (Choose sin­gle best response]a. acquired perforating disordersb. Kyrle's diseasec. reactive perforating collagenosisd. elastosisperforans serpiginosae. all of the above

6. Other perforatingdisordersincludedin the histologicdifferentialdiagnosis are (Choose as many responsesas apply.)a. reactive perforating collagenosisb. elastosisperforans serpiginosac. perforating folliculitisd. elastofibroma dorsie. Kyrle's disease

7. Transepidermal elimination of elastic tissue fre­quently occursin (Choose as many responses as ap­ply.)a. reactive perforating collagenosisb. elastosis perforans serpiginosac. Kyrle's diseased. perforating folliculitise. acquired perforating dermatosis

8. Transepidermal elimination of collagen occurs in(Choose as many responses as apply.)a. reactive perforating collagenosisb. elastosis perforans serpiginosa

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808 Self-Assessment examination

c. Kyrle's diseased. perforating folliculitise. acquired perforating dermatosis

9. Histologic features of Kyrle's disease include (Chooseas many responses as apply.)a. epidermal invagination filled with a keratotic plugb. areas of parakeratosis within the keratin plugc. linear IgA depositiond. elastic tissue perforatione. collagen perforation

10. Helpful treatments include (Choose as many re­sponses as apply.)a. d-penicillamineb. topical tretinoinc. etretinated. vitamin Ae. flutamide

QUESTIONS 11-20

A 72-year-old man had an enlarging asymptom­atic erythematous plaque on the right side of thescalp (Fig. 3), first noted by his barber severalmonths earlier. He was otherwise healthy and tookno medications.

11. The clinical differential diagnosis includes each ofthefollowing except (Choose single best response.)a. erysipelasb. angiosarcomac. epithelioid hemangioendotheliomad. ecchymosise. Kaposi's sarcoma

12. A skin biopsy specimen is shown in Fig. 4. The diag­nosis is (Choose single best response.)

Journal of the American Academy of DermatologyMay 1993

a. erysipelasb. angiosarcomac. epithelioid hemangioendotheliomad. ecchymosise. Kaposi's sarcoma

13. The most common location of cutaneous angiosar­coma is (Choose single best response.)a. trunkb. footc. lymphedematous armd. heade. lymphedematous leg

Directions for questions 14 through 17: Select theone lettered item that most closely corresponds toeach numbered item.

a. Vascular endothelial cellsb. Lymphatic endothelial cellsc. Bothd. Neither

14. Factor VIII-related antigen

15. Ulex europaeus-llectin

16. a-L-Fucose

17. Weibel-Pelade bodies

18. Metastases of cutaneous angiosarcoma of the faceand scalp most commonly involve the: (Choose sin­gle best response.)a. lungb. liverc. kidneysd. bonee. heart

Directions for questions 19 and 20: Select the onelettered item that most closely corresponds to eachnumbered item.

a. Favorable prognostic indicatorb. Unfavorable prognostic indicatorc. No prognostic significance

Journal of the American Academy of DermatologyVolume 28, Number 5, Part I

19. Marked lymphocytic infiltration

20. Lack of appendageal destruction

QUESTIONS 21-31

A 48-year-old man had red, tender nodules on theright shin of 1month's duration; they were itchy andoccasionally became crusted. He was otherwise well.He had a renal transplant 17 years previously andhas been receivingazathioprineand systemic cortico­steroids. He occasionally scratched the affectedarea, but could not recall any other trauma at thesite. Physical examination revealed several erythe­matous papules and nodules on the shin, some withcentral ulceration and exudation (Fig. 5).

21. The likely diagnoses for this man's skin diseaseinclude (Choose single best response.)a. cutaneous cryptococcosisb. atypical mycobacterial infectionc. Majocchi's granulomad. lichen simplex chronicuse. all of the above

22. Which of the following would help to establish thediagnosis? (Choose as many as apply. All, some, ornone ofthe choices may be correct.)a. Skin biopsyb. Tissue (skin) culture for fungic. Tissue (skin) culture for mycobacteria with incu­

bation at 35° Cd. Tissue (skin) culture for mycobacteria with incu­

bation at 28° to 32° Ce. Radiograph of the leg

A skin biopsy specimen of an erythematous nodulerevealed the changes shown in Figs. 6, 7 (hematox­ylin and eosin) and Fig. 8 (acid-fast stain).

23. The most likely causal organism for this man's skindisease is (Choose single best response]a. Sporothrix schenckii

Self-Assessment examination 809

b. Mycobacterium chelonaec. Mycobacterium smegmatisd. Mycobacterium tuberculosise. Mycobacterium xenopi

Tissue culture of a biopsy specimen yielded growthof M. chelonae on Lowenstein-Jensen medium.

24. Characteristics of M. chelonae include each of thefollowing except (Choose single best response.)a. rapid growth (3 to 7 days) on standard medium for

mycobacteria (i.e., Lowenstein-Jensen)b. good growth on chocolate agar and routine bacte­

riologic mediumc. resistance to therapy with standard antitubercu­

lous agentsd. a natural saprophyte with worldwide distributione. negative reaction with acid-fast staining

25. M. chelonae has produced which of the following?

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810 Self-Assessment examination

(Choose as many as apply. All, some, or none ofthechoices may be correct.)a. Postoperative infection after median sternotomy

or augmentation mammoplastyb. Pulmonary diseasec. Cutaneous nodules, abscesses, and sinus tractsd. Endocarditise. Keratitis

26. Characteristics of M. chelonae skin disease in im­munocompetent patients typically include (Choosetwo best responses.)a. an antecedent penetrating injury at the site of in-

fectionb. predilection for the upper extremityc. distinctive vesicles and bullae on reddened skind. dissemination and death likely if untreatede. an interval of weeks or months before correct di­

agnosis

27. In immunocompromised patients, M. chelonae skindisease (Choose two best responses.)a. has a predilection for the extremitiesb. has a rapidly fulminating course causing death in

most patientsc. typically produces cyclic feverd. produces leukocytosis often greater than 50,000/

mm' with a lymphocyte predominancee. often evades correct diagnosis for weeks or months

28. Histologic changes of M. chelonae skin diseaseinclude (Choose single best response.)a. acute neutrophilic microabscessesb. granulomas composed of epithelioid cells and gi­

ant cellsc. a rim of eosinophils around epithelioid cell gran­

ulomas

Journal of the American Academy of DermatologyMay 1993

d. a and be. a, b, and c

Directions for questions 29 and 30: Select the onelettered item that most closely corresponds to eachnumbered item.

a. M. tuberculosisb. M. chelonaec. Bothd. Neither

29. Susceptible to first-lineantimycobacterial drugs (e.g.,isoniazid, rifampin)

30. Intravenous amikacin and/or cefoxitin is recom­mended for initial treatment of serious disease,pending drug susceptibility tests.

31. The best current therapy for extensive skin diseasecaused by M. chelonae is (Choose single bestresponse.)a. excision of the infected areab. isoniazid and/or rifampinc. cefoxitin and amikacind. heate. x-irradiation