Test Your Knowledge With Multiple-Choice Cases Case 1 Heal my hand! A 33-year-old man presents with this 2.5 cm x 3.0 cm ulcerating, infiltrative lesion on the dorsum of his hand. It began as a papule seven weeks ago. He complains of malaise with no fever or weight loss. There is no axillary lymphadenopathy. Interestingly, the patient reveals he had travelled in Central America three months ago. Punch biopsy of the border and histologic examination reveals a dermal infiltrate consisting predominantly of large macrophages filled with great numbers of a non-encapsulated nucleated organism with some epithelioid cells and multinucleated giant cells. What is the diagnosis? a. Squamous cell carcinoma b. Cutaneous tuberculosis c. Sarcoidosis d. Cutaneous leishmaniasis e. Leprosy Cutaneous leishmaniasis (answer d) and the causative protozoal leishmania species is identified. The spectrum of disease ranges from single, localized cutaneous ulcers, to mucosal disease, to diffuse forms. John Kraft, BSc, is a third-year medical student, University of Toronto; Carrie Lynde, Bsc, is a third-year law student, University of Western Ontario; and Charles Lynde, MD, FRCP(C), is a dermatologist, Toronto, Ontario. American cutaneous leishmaniasis is endemic to many areas of Latin America and South America. The patient can be reassured that, although troublesome (due to risk of secondary bacterial infection), it is not life-threatening. Treatment depends on the infecting leishmania species, the immunologic status of the host and the patient s clinical symptoms. Options include pentavalent antimony-containing drugs, pentamidine, amphotericin B and ketoconazole. This month 4 cases: 1. Heal my hand! 2. A Papule Eruption! 3. What s on my abdomen? 4. What s happened to my ear? The Canadian Journal of CME / March 2005 17
Case 2 A Papule Eruption! A 10-year-old girl presents with a discontinuous, linear band of erythematous papules (some of which have a scaly surface) in a zosteriform distribution. The eruption appeared suddenly. She does not complain of pruritus or tenderness. What can it be? a. Herpes zoster b. Contact dermatitis c. Lichen striatus d. Lichen nitidus e. Lichen planus Lichen striatus (answer c) is a relatively uncommon eruption, predominantly occuring in children and, rarely, in adults. It usually manifests on the extremities as either a continuous or interrupted band of erythematous papules that may have a scaly surface with no itching. The lesions erupt suddenly and often involute within a year. It is not known why there tends to be a linear distribution along Blaschko s lines. Lesions may be hypopigmented in patients with dark skin. Involvement of the posterior nail fold and matrix can cause nail dystrophy. Due to the low incidence of this disease and its self-limiting nature, there have been no thorough evaluations of treatment. Topical corticosteroids may be used and there are some reports suggesting topical tacrolimus may be helpful as well. John Kraft, BSc, is a third-year medical student, University of Toronto; Carrie Lynde, Bsc, is a third-year law student, University of Western Ontario; and Charles Lynde, MD, FRCP(C), is a dermatologist, Toronto, Ontario. The Canadian Journal of CME / March 2005 19
Case 3 What s on my abdomen? A 62-year-old woman with psoriatic arthritis presents with an erythematous, irregular, serpiginous lesion in the left lower quadrant of her abdomen. The lesion erupted 10 days ago as a red papule with worsening pruritus. She has an occasional cough. She enjoys spending time at a public beach and has no pets. What do you suspect? a. Ancylostoma brasiliense b. Toxoplasma gondii c. Trypanosoma cruzi d. Leishmania mexicana e. Schistosoma mansoni This patient has cutaneous larva migrans (creeping eruption). This is an infection of the skin caused by the larvae of the cat and dog hookworm, Ancylostoma brasiliense (answer a). This hookworm reaches maturity in dogs and cats and their eggs are shed in feces where, under the right conditions (i.e., a warm, moist environment), larvae hatch. The larvae are capable of penetrating human skin and remain in the skin and migrate, producing the serpiginous lesion seen in the photo. Beaches and other moist sandy soils are common sources of ancylostoma brasiliense, especially in areas where dogs and cats frequently defecate. The treatment of choice is topical thiabendazole. John Kraft, BSc, is a third-year medical student, University of Toronto; Carrie Lynde, Bsc, is a third-year law student, University of Western Ontario; and Charles Lynde, MD, FRCP(C), is a dermatologist, Toronto, Ontario. 20 The Canadian Journal of CME / March 2005
Case 4 What s happened to my ear? A 17-year-old girl presents with multiple discrete, follicular papules on her left ear. She claims the eruption has worsened with cooler temperatures. The lesions are rough on palpation. What do you think? a. Milia b. Keratosis pilaris c. Lichen spinulosus d. Acne vulgaris e. Darier-White disease (Keratosis follicularis) Take blood ACCURETIC* is indicated in essential hypertension when combination therapy is appropriate. The fixed combination is not indicated for initial therapy. ACCUPRIL* is indicated in essential hypertension when diuretics or beta-blockers are unsuitable. WARNING: As with all ACE inhibitors, please refer to specific warnings regarding drug discontinuation in angioedema and pregnancy. Please refer to Product Monographs for complete dosing information. Multicentre, 8-week, double-blind, forced-titration study in 368 patients randomized to three parallel treatment groups. Patients included men and women, 18 years or older with supine DBP 105 and 120 mmhg at end of placebo phase. During the first four weeks patients received once-daily quinapril 10 mg plus placebo OR quinapril 10 mg plus HCTZ 12.5 mg OR placebo plus HCTZ 12.5 mg. After 4 weeks of therapy, doses were doubled and treatment continued for another 4 weeks unless supine BP was <120/80 mmhg or if there was any other clinical reason, then doses were not doubled. Data from 318 patients in the low dose group and from 284 patients in the high dose group were used for efficacy evaluation. Change in supine BP from baseline to endpoint was: -13.1/-12.1 mmhg for quinapril 10 mg; -11.6/-12.5 mmhg for HCTZ 12.5 mg; 17.7/-14.6 mmhg for the low-dose combination; -19.7/-17.0 mmhg for quinapril 20 mg; -20.4/-17.2 mmhg for HCTZ 25 mg; and -27.1/-19.5 mmhg for the high-dose combination. One price for all dosage strengths. Price does not include pharmacy professional fees. Please refer to Product Monograph for complete dosing information.
Keratosis pilaris (answer b) is a common condition, especially in children and adolescents, that frequently presents with lesions on the lateral aspects of the upper arms, thighs and buttocks. Individual lesions are typically discrete, keratotic, follicular papules, sometimes containing a coiled hair that may be surrounded by erythema. Lesions feel rough when palpated. Eruptions are often exacerbated by cold temperatures. Keratosis pilaris is often familial and may be associated with atopic dermatitis or ichthyosis vulgaris. The patient s keratosis pilaris was treated with a keratolytic gel containing salicylic acid and an emollient cream to help alleviate the rough surface. John Kraft, BSc, is a third-year medical student, University of Toronto; Carrie Lynde, Bsc, is a third-year law student, University of Western Ontario; and Charles Lynde, MD, FRCP(C), is a dermatologist, Toronto, Ontario. pressure control further...with Extend the control of quinapril or HCTZ alone, with the fastest growing fixed-dose combination ACCURETIC* is the fastest growing Significantly greater BP lowering power than quinapril or HCTZ in monotherapy (p>0.05) 6 Excellent tolerability profile 3 The flexibility of 7 dosage options across the ACCUPRIL* and ACCURETIC* range, all at the same price 1,3,4 ACE-I/HCTZ fixed-dose combination choice in new and total prescriptions 5 The most frequent adverse events for ACCURETIC* in controlled trials were headache (6.7%), dizziness (4.8%), cough (3.2%) and fatigue (2.9%). For the complete list of adverse events, please refer to the Product Monograph. 2005 Pfizer Canada Inc. Kirkland, Quebec H9J 2M5 *TM Parke, Davis & Company Pfizer Canada Inc., licensee (quinapril hydrochloride and hydrochlorothiazide) POWER OF COMBINED CONTROL For prescribing information see page 110