Practice questions papulosquamous disorders

Practice questions

Papulosquamous disorders

Updated: 03/05/2019

© Jun Wang, MD, PhD

1. Use this image and this case for the next three questions. A 44-year-old man presents with pruritic left forearm lesion for 2 years. The symptoms are worse in winter but better in summer. His past medical history include type 2 diabetes and multiple skin squamous cell carcinoma and basal cell carcinoma. An image of the lesion is shown. Biopsy reveals skin with elongated rete ridges and focal absence of granular layers. No cytological atypia is noted. Special stain is negative for fungal hyphae. What is the diagnosis?

(Image credit: MediaJet [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. Dermatophytosis

B. Lichen planus

C. Psoriasis

D. Seborrheic dermatitis

E. Squamous cell carcinoma

2. A 44-year-old man presents with pruritic left forearm lesion for 2 years. The symptoms are worse in winter but better in summer. His past medical history include type 2 diabetes and multiple skin squamous cell carcinoma and basal cell carcinoma. An image of the lesion is shown. Biopsy reveals skin with elongated rete ridges and focal absence of granular layers. No cytological atypia is noted. Special stain is negative for fungal hyphae. What is causing these presentations?

 (Image credit: MediaJet [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. Abnormal cornification due to elevated cytokine levels

B. Autoimmune destruction of keratinocytes

C. Chronic inflammation due to fungal infection

D. Malignant transformation caused by UV light

E. Treponema pallidum induced acute and chronic inflammation

3. A 44-year-old man presents with pruritic left forearm lesion for 2 years. The symptoms are worse in winter but better in summer. His past medical history include type 2 diabetes and multiple skin squamous cell carcinoma and basal cell carcinoma. An image of the lesion is shown. Biopsy reveals skin with elongated rete ridges and focal absence of granular layers. No cytological atypia is noted. Special stain is negative for fungal hyphae. Abnormality of what gene is likely associated with these findings?

(Image credit: MediaJet [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. BRAF

B. FGFR3

C. LCE3

D. P53

E. PTCH

4. Use this image for this question. A 29-year-old man presents with slightly pruritic lesions at his back. His medical history is unremarkable. He is sexually active with one partner. He does not smoke cigarette nor drink alcohol. An image of these lesions are shown. Biopsy reveals epidermal hyperplasia with focal intraepidermal microabscesses within parakeratotic layers. No significant inflammation is noted at dermis and dermoepidermal junction. What is most likely the diagnosis?

(Image credit: Bobjgalindo [CC BY-SA 4.0 (https:\creativecommons.org\licenses\by-sa\4.0)], the image has been cropped)

A. Guttate psoriasis

B. Lichen planus

C. Pityriasis rosea

D. Seborrheic dermatitis

E. Secondary syphilis

5. Use this case for the next two questions. A 65-year-old woman presents with fever and widespread pruritic pustules for 1 day. These lesions first appear at her left forearm, and rapidly spread to her face, chest and back. Her past medical history including diabetes and hypertension. Physical examination reveals numerous small pustules, with focal erosion. The background skin has erythematous changes. Her nails are thickened with pits and yellowish discoloration. Her CBC is unremarkable except mild leukocytosis. Biopsy of the skin lesion reveal epidermal hyperplasia with parakeratosis and numerous neutrophilic aggregates, especially at the thinned granular layer. No significant cytological atypia nor lymphocytic infiltration is seen. Special stain reveals no evidence of fungal hyphae. What is likely the diagnosis?

A. Dermatitis herpetiformis

B. Lichen planus

C. Pityriasis rosea

D. Pustular psoriasis

E. Secondary syphilis

6. A 65-year-old woman presents with fever and widespread pruritic pustules for 1 day. These lesions first appear at her left forearm, and rapidly spread to her face, chest and back. Her past medical history including diabetes and anemia. Physical examination reveals numerous small pustules, with focal erosion. The background skin has erythematous changes. Her nails are thickened with pits and yellowish discoloration. Her CBC is unremarkable except mild leukocytosis. Biopsy of the skin lesion reveal epidermal hyperplasia with parakeratosis and numerous neutrophilic aggregates, especially at the thinned granular layer. No significant cytological atypia nor lymphocytic infiltration is seen. Special stain reveals no evidence of fungal hyphae. What is likely the cause of her nail presentation?

A. Autoimmune destruction of keratinocytes

B. Cornification defect

C. Fungal infection

D. Hyperglycemia

E. Malnutrition

7. A 46-year-old man presents with pain and stiffness of his hands for 2 years. He has a history of sclerosing sialadenitis, psoriasis and type 2 diabetes. Physical examination reveals several tender and swollen interphaglangeal joints bilaterally. Laboratory tests, including rheumatic factor, are within normal range. What is likely the diagnosis?

A. Infectious arthritis

B. Psoriatic arthritis

C. Rheumatic arthritis

D. Rheumatoid arthritis

8. An 11-year-old girl presents with redness and watering from both eyes for 2 days. She has had slightly pruritic skin rash and deformed nails for 1 year, that the parents treated with antifungal agents. Her past medical history is otherwise unremarkable. Physical examination reveals reduced a few white plaques at her arms and left shoulder. Her nails are thickened with pits. Her joints are unremarkable. No abnormalities are noted in range of motion nor muscle strength. Examination of her eyes reveals reduced visual acuity. Her conjunctiva are edematous and erythematous. Her laboratory tests are within normal range. Biopsy of the skin lesion reveals marked epidermal hyperplasia with evenly elongated rete ridges, parakeratosis and focal neutrophilic microabscesses within parakeratotic area. Special stain is negative for fungal hyphae. What is likely the diagnosis?

A. Chlamydia conjunctivitis

B. Fungal conjunctivitis

C. Psoriatic conjunctivitis

D. Viral conjunctivitis

9. Use this case for the next two questions. A 4-year-old boy presents with pruritic rash around his nose, including nasolabial folds, for a year. His past medical history is unremarkable. Physical examination reveals well demarcated erythematous plaques with yellowish scales. No other abnormalities are noted. What is most likely the diagnosis?

A. Atopic dermatitis

B. Pemphigus erythematosus

C. Psoriasis

D. Seborrheic dermatitis

E. Systemic lupus erythematosus

10. A 4-year-old boy presents with pruritic rash around his nose, including nasolabial folds, for a year. His past medical history is unremarkable. Physical examination reveals well demarcated erythematous plaques with yellowish scales. No other abnormalities are noted. What is most likely associated with his presentations?

A. Autoimmune process

B. Bacterial infection

C. Cornification defect

D. Fungal colonies

E. Viral infection

11. Use this image and this case for the next four questions. A 25-year-old man presents with pruritic skin lesions at his forearms for a year. He had a headache a week ago and took motrin for a few days. His past medical history is unremarkable. He is a social drinker but does not smoke cigarette. Physical examination reveals slight yellowish discoloration of his sclera. The lesions are shown. Laboratory tests reveals a bilirubin 9.5 mg/dL (normal 0.1-1.2 mg/dL), direct bilirubin of 5.7 mg/dL (normal 0.1-0.5 mg/dL), AST of 752 U/L (normal 5-35 U/L) and ALT of 872 U/L (normal 7-56 U/L). Biopsy of the skin lesion reveals marked lymphocytic infiltratation at the dermoepidermal junction. Apoptotic keratiniocytes are seen at the basal layer. What is most likely the diagnosis of the skin lesion?

(Image credit: Tag-El -Din Anbar MD, Manal Barakat MD, and Sahar F Ghannam MD PhD [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. Dermatophytosis

B. Lichen planus

C. Pityriasis rosea

D. Pustular psoriasis

E. Secondary syphilis

12. A 25-year-old man presents with pruritic skin lesions at his forearms for a year. He had a headache a week ago and took motrin for a few days. His past medical history is unremarkable. He is a social drinker but does not smoke cigarette. Physical examination reveals slight yellowish discoloration of his sclera. The lesions are shown. Laboratory tests reveals a bilirubin 9.5 mg/dL (normal 0.1-1.2 mg/dL), direct bilirubin of 5.7 mg/dL (normal 0.1-0.5 mg/dL), AST of 752 U/L (normal 5-35 U/L) and ALT of 872 U/L (normal 7-56 U/L). Biopsy of the skin lesion reveals marked lymphocytic infiltratation at the dermoepidermal junction. Apoptotic keratiniocytes are seen at the basal layer. What is likely finding for immunofluoscence studies?

(Image credit: Tag-El -Din Anbar MD, Manal Barakat MD, and Sahar F Ghannam MD PhD [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. Clumped deposit of IgM at dermoepidermal junction

B. Deposit of IgG along epidermal intercellular junctions

C. Granular deposit of IgA at dermal papillae

D. Linear deposit of IgG along dermoepidermal junction

E. Linear deposit of complements along dermoepidermal junction

13. A 25-year-old man presents with pruritic skin lesions at his forearms for a year. He had a headache a week ago and took motrin for a few days. His past medical history is unremarkable. He is a social drinker but does not smoke cigarette. Physical examination reveals slight yellowish discoloration of his sclera. The lesions are shown. Laboratory tests reveals a bilirubin 9.5 mg/dL (normal 0.1-1.2 mg/dL), direct bilirubin of 5.7 mg/dL (normal 0.1-0.5 mg/dL), AST of 752 U/L (normal 5-35 U/L) and ALT of 872 U/L (normal 7-56 U/L). Biopsy of the skin lesion reveals marked lymphocytic infiltratation at the dermoepidermal junction. Apoptotic keratiniocytes are seen at the basal layer.

A few weeks later, the same lesions developed at his left leg, after he had a skin abrasion due to a fall. What is likely causing his new lesions?

(Image credit: Tag-El -Din Anbar MD, Manal Barakat MD, and Sahar F Ghannam MD PhD [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. Autoimmune process

B. Koebner phenomenon

C. Local bacterial infection

D. Sepsis

E. Spreaded fungal infection

14. A 25-year-old man presents with pruritic skin lesions at his forearms for a year. He had a headache a week ago and took motrin for a few days. His past medical history is unremarkable. He is a social drinker but does not smoke cigarette. Physical examination reveals slight yellowish discoloration of his sclera. The lesions are shown. Laboratory tests reveals a bilirubin 9.5 mg/dL (normal 0.1-1.2 mg/dL), direct bilirubin of 5.7 mg/dL (normal 0.1-0.5 mg/dL), AST of 752 U/L (normal 5-35 U/L) and ALT of 872 U/L (normal 7-56 U/L). Biopsy of the skin lesion reveals marked lymphocytic infiltratation at the dermoepidermal junction. Apoptotic keratiniocytes are seen at the basal layer. What is likely to cause his abnormal liver function tests?

(Image credit: Tag-El -Din Anbar MD, Manal Barakat MD, and Sahar F Ghannam MD PhD [CC BY-SA 3.0 (https:\creativecommons.org\licenses\by-sa\3.0)])

A. Alcohol toxicity

B. Drug induced liver damage

C. Hepatitis C

D. Hepatocellular carcinoma

E. Portal vein thrombosis

15. Use this case for the next two questions. A 31-year-old woman presents with burning sensation of scalp and hair loss for a week. She has a history of obesity and type 1 diabetes. Her family history is positive for alopecia areata. Physical examination reveals irregular patches with fine grey scales and erythematous changes at the occipital area. No other abnormality is seen. Biopsy reveals skin with hypergranulosis and dense lymphocytic infiltrate at the dermoepidermal junction of hair-follicles. There is no significant spongiosis nor epidermal hyperplasia. Special stain reveals a few fungal yeast, but no hyphae are noted. What is the diagnosis?

A. Dermatophytosis

B. Lichen planopilaris

C. Psoriasis

D. Seborrheic dermatitis

E. Secondary syphilis

16. A 31-year-old woman presents with burning sensation of scalp and hair loss for a week. She has a history of obesity and type 1 diabetes. Her family history is positive for alopecia areata. Physical examination reveals irregular patches with fine grey scales and erythematous changes at the occipital area. No other abnormality is seen. Biopsy reveals skin with hypergranulosis and dense lymphocytic infiltrate at the dermoepidermal junction of hair-follicles. There is no significant spongiosis nor epidermal hyperplasia. Special stain reveals a few fungal yeast, but no hyphae are noted. What is causing her presentations?

A. Autoimmune process

B. Bacterial infection

C. Cornification defect

D. Fungal colonies

E. Viral infection

17. Use this image and this case for the next two questions. A 28-year-old man presents widespread slightly pruritic skin rashes for 2 weeks. The first rash is a large irregular erythematous lesion at the left upper arm. Within a few days, numerous smaller pink rash with fine scales spread through his chest and back. He does not have fever nor fatigue. He received a flu-shot a month ago. He has an infectious mononucleosis at age 21, and shingles 5 years ago. Physical examination reveals rashes as shown. Biopsy of the lesion reveals skin with mild epidermal hyperplasia and spongiosis, and scattered lymphocytic infiltrate. The dermoepidermal junction is unremarkable. Special stains reveal no evidence of fungal hyphae. What is the diagnosis?

(Image credit: Aceofhearts1968 [Public domain]/wiki commons)

A. Guttate psoriasis

B. Lichen planus

C. Pityriasis rosea

D. Seborrheic dermatitis

E. Secondary syphilis

18. A 28-year-old man presents widespread slightly pruritic skin rashes for 2 weeks. The first rash is a large irregular erythematous lesion at the left upper arm. Within a few days, numerous smaller pink rash with fine scales spread through his chest and back. He does not have fever nor fatigue. He received a flu-shot a month ago. He has an infectious mononucleosis at age 21, and shingles 5 years ago. Physical examination reveals rashes as shown. Biopsy of the lesion reveals skin with mild epidermal hyperplasia and spongiosis, and scattered lymphocytic infiltrate. The dermoepidermal junction is unremarkable. Special stains reveal no evidence of fungal hyphae. What is likely to be associated with these findings?

A. EB virus

B. Flu shot

C. Human herpes virus 1

D. Malassezia

E. Treponema pallidum

19. Use this image and this case for the next two questions. A 22-year-old man presents with low grade fever, generalized weakness, headache and wide-spread painless, nonpruritic rashes on his skin. He had an ulcer at his glans 2 years ago that was treated with antibiotics. He is sexually active with multiple male partners. He is allergic to penicillin with skin rashes. Physical examination reveals pink irregular macules as shown. Biopsy reveals skin with dense plasma cell infiltrate in dermis. The epidermis is and dermoepidermal junctions are relatively unremarkable. What is the diagnosis?

(Image credit: Office of Medical History, US Surgeon General [Public domain])

A. Guttate psoriasis

B. Lichen planus

C. Pityriasis rosea

D. Seborrheic dermatitis

E. Secondary syphilis

20. A 22-year-old man presents with low grade fever, generalized weakness, headache and wide-spread painless, nonpruritic rashes on his skin. He had an ulcer at his glen 2 years ago that was treated with antibiotics. He is sexually active with multiple male partners. He is allergic to penicillin with skin rashes. Physical examination reveals pink irregular macules as shown. Biopsy reveals skin with dense plasma cell infiltrate in dermis. The epidermis is and dermoepidermal junctions are relatively unremarkable. What blood test is likely to confirm the diagnosis?

(Image credit: Office of Medical History, US Surgeon General [Public domain])

A. Culture

B. Flow cytometry

C. Monospot

D. RT-PCR for HIV RNA

E. Treponema pallidum hemagglutination assay

21. A 19-year-old woman presents with a mildly pruritic lesion at her left shoulder. She has a history of systemic lupus erythematosus and is currently being treated with steroids. Physical examination reveals a 2.5 cm oval rash with erythematous base and fine silver scale at the periphery. Biopsy reveal skin with parakeratosis, mild spongiosis, and intraepidermal neutrophilic infiltrate. Silver stain is shown. What is the diagnosis?

(Image credit: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])

A. Dermatophytosis

B. Pityriasis rosea

C. Psoriasis

D. Seborrheic dermatitis

E. Secondary syphilis

Answers

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